William G. Wilkoff, MD

Two weeks ago, I received a few video clips of my granddaughter’s 5th birthday party. Although my daughter had loosely scripted a fairy-themed event, she was wise enough to have stepped back and let the children freewheel. What I watched was a half a dozen 4- and 5-year-old girls wearing their self-decorated fairy wings running and running and running in a tree-shaded park jumping (or in their minds flying) on and off a small stage yelling "Calling all fairies, calling all fairies." Forty minutes of nonstop running and jumping, a cupcake and small scoop of ice cream, and that was it ... the perfect party.

No one was coaching these little cherubs to run. No one had set up traffic cones or a finish line. No ribbons or plastic medals were awarded in recognition of their participation. They were running for the sheer pleasure of activity, driven by what is probably an inborn urge to move. Every toddler I have known functions like a tightly wound windup toy ready to hit the ground running when placed down on the straight flat surface of a shopping mall or airport concourse.

It appears that this drive to run is not unique to young Homo sapiens. Two Dutch scientists set up a small running wheel in a wooded setting and then using motion sensors and remote video recorders watched what happened (Proc. R. Soc. B 2014 [doi:10.1098/rspb.2014.0210]). It turns out that wild mice enjoy running, spending from 1 to 18 minutes freewheeling. Frogs also occasionally jumped on and off the wheel, but running was obviously not their thing.

While the drive to run seems to be bred into us, unfortunately it is an urge that is easily extinguished. One needs only to watch a physical education class of sixth graders being asked to do a 1-mile run/walk to become painfully aware that too many children can no longer run, let alone do it for the pure enjoyment. How did such a strong drive disappear?

I wonder what would have happened if the Dutch investigators had put a smart phone with a colorful app running next to the wheel. How many of the mice have chosen to sit down and watch the screen instead of climbing on for a run? If a small electric train running in a circle had been placed next in the environment, would some of the mice have preferred to hop on for a ride? Or suppose they had played a recording of an older mouse squeaking a warning call that was the rodent equivalent of "Don’t climb on that; you could hurt yourself"?

I certainly believe (and there is animal evidence to support) that certain individuals inherit a preference for a sedentary lifestyle. However, I am equally sure that we have created a society that provides an abundance of powerfully attractive sedentary options to remaining active. In my mind, first and foremost among these attractions is color television (I don’t recall black and white TV being all that exciting). The magnetic attraction of colorful and active video images is difficult for anyone to resist. As pediatricians, we must continue to preach the word about the health hazards associated with screen time. And, I would add again my plea for us to spend less energy on worrying about what’s on the screen and instead emphasize the need to keep the exposure time down.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

Two weeks ago, I received a few video clips of my granddaughter’s 5th birthday party. Although my daughter had loosely scripted a fairy-themed event, she was wise enough to have stepped back and let the children freewheel. What I watched was a half a dozen 4- and 5-year-old girls wearing their self-decorated fairy wings running and running and running in a tree-shaded park jumping (or in their minds flying) on and off a small stage yelling "Calling all fairies, calling all fairies." Forty minutes of nonstop running and jumping, a cupcake and small scoop of ice cream, and that was it ... the perfect party.

No one was coaching these little cherubs to run. No one had set up traffic cones or a finish line. No ribbons or plastic medals were awarded in recognition of their participation. They were running for the sheer pleasure of activity, driven by what is probably an inborn urge to move. Every toddler I have known functions like a tightly wound windup toy ready to hit the ground running when placed down on the straight flat surface of a shopping mall or airport concourse.

It appears that this drive to run is not unique to young Homo sapiens. Two Dutch scientists set up a small running wheel in a wooded setting and then using motion sensors and remote video recorders watched what happened (Proc. R. Soc. B 2014 [doi:10.1098/rspb.2014.0210]). It turns out that wild mice enjoy running, spending from 1 to 18 minutes freewheeling. Frogs also occasionally jumped on and off the wheel, but running was obviously not their thing.

While the drive to run seems to be bred into us, unfortunately it is an urge that is easily extinguished. One needs only to watch a physical education class of sixth graders being asked to do a 1-mile run/walk to become painfully aware that too many children can no longer run, let alone do it for the pure enjoyment. How did such a strong drive disappear?

I wonder what would have happened if the Dutch investigators had put a smart phone with a colorful app running next to the wheel. How many of the mice have chosen to sit down and watch the screen instead of climbing on for a run? If a small electric train running in a circle had been placed next in the environment, would some of the mice have preferred to hop on for a ride? Or suppose they had played a recording of an older mouse squeaking a warning call that was the rodent equivalent of "Don’t climb on that; you could hurt yourself"?

I certainly believe (and there is animal evidence to support) that certain individuals inherit a preference for a sedentary lifestyle. However, I am equally sure that we have created a society that provides an abundance of powerfully attractive sedentary options to remaining active. In my mind, first and foremost among these attractions is color television (I don’t recall black and white TV being all that exciting). The magnetic attraction of colorful and active video images is difficult for anyone to resist. As pediatricians, we must continue to preach the word about the health hazards associated with screen time. And, I would add again my plea for us to spend less energy on worrying about what’s on the screen and instead emphasize the need to keep the exposure time down.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

Two weeks ago, I received a few video clips of my granddaughter’s 5th birthday party. Although my daughter had loosely scripted a fairy-themed event, she was wise enough to have stepped back and let the children freewheel. What I watched was a half a dozen 4- and 5-year-old girls wearing their self-decorated fairy wings running and running and running in a tree-shaded park jumping (or in their minds flying) on and off a small stage yelling "Calling all fairies, calling all fairies." Forty minutes of nonstop running and jumping, a cupcake and small scoop of ice cream, and that was it ... the perfect party.

No one was coaching these little cherubs to run. No one had set up traffic cones or a finish line. No ribbons or plastic medals were awarded in recognition of their participation. They were running for the sheer pleasure of activity, driven by what is probably an inborn urge to move. Every toddler I have known functions like a tightly wound windup toy ready to hit the ground running when placed down on the straight flat surface of a shopping mall or airport concourse.

It appears that this drive to run is not unique to young Homo sapiens. Two Dutch scientists set up a small running wheel in a wooded setting and then using motion sensors and remote video recorders watched what happened (Proc. R. Soc. B 2014 [doi:10.1098/rspb.2014.0210]). It turns out that wild mice enjoy running, spending from 1 to 18 minutes freewheeling. Frogs also occasionally jumped on and off the wheel, but running was obviously not their thing.

While the drive to run seems to be bred into us, unfortunately it is an urge that is easily extinguished. One needs only to watch a physical education class of sixth graders being asked to do a 1-mile run/walk to become painfully aware that too many children can no longer run, let alone do it for the pure enjoyment. How did such a strong drive disappear?

I wonder what would have happened if the Dutch investigators had put a smart phone with a colorful app running next to the wheel. How many of the mice have chosen to sit down and watch the screen instead of climbing on for a run? If a small electric train running in a circle had been placed next in the environment, would some of the mice have preferred to hop on for a ride? Or suppose they had played a recording of an older mouse squeaking a warning call that was the rodent equivalent of "Don’t climb on that; you could hurt yourself"?

I certainly believe (and there is animal evidence to support) that certain individuals inherit a preference for a sedentary lifestyle. However, I am equally sure that we have created a society that provides an abundance of powerfully attractive sedentary options to remaining active. In my mind, first and foremost among these attractions is color television (I don’t recall black and white TV being all that exciting). The magnetic attraction of colorful and active video images is difficult for anyone to resist. As pediatricians, we must continue to preach the word about the health hazards associated with screen time. And, I would add again my plea for us to spend less energy on worrying about what’s on the screen and instead emphasize the need to keep the exposure time down.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

Thirty-five years ago my wife was the volunteer coordinator at the grade school down the street. She seldom had to do much coordinating because there weren’t many volunteers. My daughter-in-law currently holds the same position in the same school. And although she would always like to have additional volunteers, she manages many more than my wife ever did.

When I was a child, if I saw a parent in the school it was a bad sign. Either someone had gotten sick or some poor soul had done something that had put him on the path to expulsion. School was a treasured parent-free zone, my own little social laboratory where I could experiment with the person I was going to be when I grew up.

But now parental involvement is viewed as one of the keystones of child rearing. Parents feel they need to be active participants in their child’s schooling, and this has increased parental involvement in the classroom. This would seem to be a good thing, propelled partly by a genuine desire to help schools where resources are being stretched thin by budgetary constraints. But occasionally, volunteering is a misguided attempt to deal with unresolved, sometimes bidirectional, separation anxiety.

And I fear that sometimes volunteering is a cover story for spying. Most children are stingy with stories about their school days. "What happened in school today?" The typical response is "nothing special." Unless of course, "Rachel vomited on her desk during math this morning."

I have always suspected that parental involvement is a double-edged sword. And some recent work by two sociology professors – Keith Robinson of the University of Texas in Austin and Angel L. Harris of Duke University in Durham, N.C. – suggests that the blade more often cuts in an unintended direction ("Parental Involvement Is Overrated" – New York Times Sunday Review, April 13, 2014). Their longitudinal study involved a survey of American families in the 1980’s to the 2000’s that looked at demographics, ethnicity, socioeconomic status, and levels of parental engagement (not just classroom volunteering) in relation to academic outcomes.

What they discovered was that in two groups divided by ethnicity and race but with similar levels of parental involvement, the children whose families valued education less highly did less well academically. The investigators also discovered that most forms of parental involvement "yielded no benefit to children’s test scores or grades regardless of racial or ethnic background or socioeconomic standing." In fact, when involvement did make a difference, it was more often negative.

Although most of us believe that regular reading to elementary school children has a positive effect, these authors found that while white and Hispanic children benefited, blacks did not. Obviously, parental involvement is a complex factor in children’s lives, and we must be careful about making assumptions before we make blanket recommendations. For example "consistent help with homework never improved test scores or grades," and in fact, regular help usually resulted in poorer performance.

However, parents can have a positive effect when they make it clear from the beginning that they value education and expect the child will go to college. Requesting a particular teacher helps as does discussing the child’s school activities at home. However, parents must expect that most of these discussions will be short.

I suspect that the professors would agree with my suggestion to parents that if they would like to help in the schools, they should volunteer in a classroom other than their own child’s, or even better, run the copier machine in the office or sweep out the equipment room in the gym.

Most of us cringe when we hear about extreme cases of helicopter parenting when parents rent apartments near campuses to be close to their college age children. But, few of us would have predicted the findings of this study that suggest parental involvement in younger children’s school lives is not only ineffective but often detrimental. As pediatricians, we can help parents do the counterintuitive thing and as these authors suggest, "set the stage and then get off."

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

Thirty-five years ago my wife was the volunteer coordinator at the grade school down the street. She seldom had to do much coordinating because there weren’t many volunteers. My daughter-in-law currently holds the same position in the same school. And although she would always like to have additional volunteers, she manages many more than my wife ever did.

When I was a child, if I saw a parent in the school it was a bad sign. Either someone had gotten sick or some poor soul had done something that had put him on the path to expulsion. School was a treasured parent-free zone, my own little social laboratory where I could experiment with the person I was going to be when I grew up.

But now parental involvement is viewed as one of the keystones of child rearing. Parents feel they need to be active participants in their child’s schooling, and this has increased parental involvement in the classroom. This would seem to be a good thing, propelled partly by a genuine desire to help schools where resources are being stretched thin by budgetary constraints. But occasionally, volunteering is a misguided attempt to deal with unresolved, sometimes bidirectional, separation anxiety.

And I fear that sometimes volunteering is a cover story for spying. Most children are stingy with stories about their school days. "What happened in school today?" The typical response is "nothing special." Unless of course, "Rachel vomited on her desk during math this morning."

I have always suspected that parental involvement is a double-edged sword. And some recent work by two sociology professors – Keith Robinson of the University of Texas in Austin and Angel L. Harris of Duke University in Durham, N.C. – suggests that the blade more often cuts in an unintended direction ("Parental Involvement Is Overrated" – New York Times Sunday Review, April 13, 2014). Their longitudinal study involved a survey of American families in the 1980’s to the 2000’s that looked at demographics, ethnicity, socioeconomic status, and levels of parental engagement (not just classroom volunteering) in relation to academic outcomes.

What they discovered was that in two groups divided by ethnicity and race but with similar levels of parental involvement, the children whose families valued education less highly did less well academically. The investigators also discovered that most forms of parental involvement "yielded no benefit to children’s test scores or grades regardless of racial or ethnic background or socioeconomic standing." In fact, when involvement did make a difference, it was more often negative.

Although most of us believe that regular reading to elementary school children has a positive effect, these authors found that while white and Hispanic children benefited, blacks did not. Obviously, parental involvement is a complex factor in children’s lives, and we must be careful about making assumptions before we make blanket recommendations. For example "consistent help with homework never improved test scores or grades," and in fact, regular help usually resulted in poorer performance.

However, parents can have a positive effect when they make it clear from the beginning that they value education and expect the child will go to college. Requesting a particular teacher helps as does discussing the child’s school activities at home. However, parents must expect that most of these discussions will be short.

I suspect that the professors would agree with my suggestion to parents that if they would like to help in the schools, they should volunteer in a classroom other than their own child’s, or even better, run the copier machine in the office or sweep out the equipment room in the gym.

Most of us cringe when we hear about extreme cases of helicopter parenting when parents rent apartments near campuses to be close to their college age children. But, few of us would have predicted the findings of this study that suggest parental involvement in younger children’s school lives is not only ineffective but often detrimental. As pediatricians, we can help parents do the counterintuitive thing and as these authors suggest, "set the stage and then get off."

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

Thirty-five years ago my wife was the volunteer coordinator at the grade school down the street. She seldom had to do much coordinating because there weren’t many volunteers. My daughter-in-law currently holds the same position in the same school. And although she would always like to have additional volunteers, she manages many more than my wife ever did.

When I was a child, if I saw a parent in the school it was a bad sign. Either someone had gotten sick or some poor soul had done something that had put him on the path to expulsion. School was a treasured parent-free zone, my own little social laboratory where I could experiment with the person I was going to be when I grew up.

But now parental involvement is viewed as one of the keystones of child rearing. Parents feel they need to be active participants in their child’s schooling, and this has increased parental involvement in the classroom. This would seem to be a good thing, propelled partly by a genuine desire to help schools where resources are being stretched thin by budgetary constraints. But occasionally, volunteering is a misguided attempt to deal with unresolved, sometimes bidirectional, separation anxiety.

And I fear that sometimes volunteering is a cover story for spying. Most children are stingy with stories about their school days. "What happened in school today?" The typical response is "nothing special." Unless of course, "Rachel vomited on her desk during math this morning."

I have always suspected that parental involvement is a double-edged sword. And some recent work by two sociology professors – Keith Robinson of the University of Texas in Austin and Angel L. Harris of Duke University in Durham, N.C. – suggests that the blade more often cuts in an unintended direction ("Parental Involvement Is Overrated" – New York Times Sunday Review, April 13, 2014). Their longitudinal study involved a survey of American families in the 1980’s to the 2000’s that looked at demographics, ethnicity, socioeconomic status, and levels of parental engagement (not just classroom volunteering) in relation to academic outcomes.

What they discovered was that in two groups divided by ethnicity and race but with similar levels of parental involvement, the children whose families valued education less highly did less well academically. The investigators also discovered that most forms of parental involvement "yielded no benefit to children’s test scores or grades regardless of racial or ethnic background or socioeconomic standing." In fact, when involvement did make a difference, it was more often negative.

Although most of us believe that regular reading to elementary school children has a positive effect, these authors found that while white and Hispanic children benefited, blacks did not. Obviously, parental involvement is a complex factor in children’s lives, and we must be careful about making assumptions before we make blanket recommendations. For example "consistent help with homework never improved test scores or grades," and in fact, regular help usually resulted in poorer performance.

However, parents can have a positive effect when they make it clear from the beginning that they value education and expect the child will go to college. Requesting a particular teacher helps as does discussing the child’s school activities at home. However, parents must expect that most of these discussions will be short.

I suspect that the professors would agree with my suggestion to parents that if they would like to help in the schools, they should volunteer in a classroom other than their own child’s, or even better, run the copier machine in the office or sweep out the equipment room in the gym.

Most of us cringe when we hear about extreme cases of helicopter parenting when parents rent apartments near campuses to be close to their college age children. But, few of us would have predicted the findings of this study that suggest parental involvement in younger children’s school lives is not only ineffective but often detrimental. As pediatricians, we can help parents do the counterintuitive thing and as these authors suggest, "set the stage and then get off."

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

Let’s be honest. Although pediatricians invest most of their days, some of their nights, and untold cockles of heartfelt concern trying to keep their patients well, there is very little evidence that what we do actually makes a difference. The one shining exception comes when we administer immunizations. This humbling fact makes the problem of vaccine refusal so frustrating and depressing.

I have always considered the increasing number of parents who refuse or who are hesitant about immunization just another example of decay in our nation’s educational system. How could anyone who was even half awake in American History class not be aware of the toll that infectious diseases took on the children born before 1900? Diseases that are now preventable. Do introductory science courses even touch on the basic mechanisms that underlie immunizations? High school students may not be expected to know that John Enders was the lead investigator in the development of the measles vaccine, but someone should have told them the story of Jonas Salk and polio.

Like many of you, I assumed that if I could just do a better job of filling in the gaps in our educational system that vaccine-hesitant parents would see the light. If I could share with parents even a small fraction of what I know about the efficacy of vaccines they couldn’t possibly refuse to immunize their children. However, after 40 years of failed attempts and frustration, I have begun to doubt my communication skills.

Some work by Brendan Nyhan, Ph.D., a government professor at Dartmouth College, and his colleagues suggests that my attempts at education were destined to fail. ("Effective Messages in Vaccine Promotion: A Randomized Trial," [Pediatrics 2014;133:1-8]). Aware that people frequently resist information that contradicts their views, these investigators began a small study. Nearly 1,800 parents were randomized to receive one of four messages supporting the value of MMR vaccine from textual excerpts to pictures of children with the diseases prevented by the vaccine.

What they discovered was that parents who had "mixed or negative feelings" about the vaccine were actually less likely to say that they would choose to vaccinate a future child after they had been presented with literature refuting the MMR-autism link. While these families were less likely to accept the vaccine-autism link, the informational materials had prompted them to consider other reasons that supported their negative views about vaccines.

Although other studies have found that parents still consider their children’s doctor to be the most trusted source of vaccine information, it appears that education as we understand it may not be our best tool. In fact, it may even be counterproductive. Attempts to engender fear may seem logical to us, but in reality they may be backfiring.

Dr. Nyhan and his colleagues didn’t bore down to discover what factors made a particular view so resistant to education. But, in my experience inheritance doesn’t seem to play a role. I hear from many fearful and frustrated grandparents who can’t understand why their grandchildren aren’t being immunized.

There is the hermit mentality that says by keeping apart from "all those other people" in society and by living a better life, we can protect ourselves from their diseases and don’t need immunizations. And, of course, there is the notion that even though we understand the rationale for immunization, God will protect us.

This important study suggests that we must be very thoughtful about our attempts at education in all public health issues. Our intuition has failed us here. As unfair as it may be to the child victims of this parental foolishness, we may need to fall back on strict exclusion and quarantine to protect the rest us until we learn how to convince families that they are making a serious mistake.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

Let’s be honest. Although pediatricians invest most of their days, some of their nights, and untold cockles of heartfelt concern trying to keep their patients well, there is very little evidence that what we do actually makes a difference. The one shining exception comes when we administer immunizations. This humbling fact makes the problem of vaccine refusal so frustrating and depressing.

I have always considered the increasing number of parents who refuse or who are hesitant about immunization just another example of decay in our nation’s educational system. How could anyone who was even half awake in American History class not be aware of the toll that infectious diseases took on the children born before 1900? Diseases that are now preventable. Do introductory science courses even touch on the basic mechanisms that underlie immunizations? High school students may not be expected to know that John Enders was the lead investigator in the development of the measles vaccine, but someone should have told them the story of Jonas Salk and polio.

Like many of you, I assumed that if I could just do a better job of filling in the gaps in our educational system that vaccine-hesitant parents would see the light. If I could share with parents even a small fraction of what I know about the efficacy of vaccines they couldn’t possibly refuse to immunize their children. However, after 40 years of failed attempts and frustration, I have begun to doubt my communication skills.

Some work by Brendan Nyhan, Ph.D., a government professor at Dartmouth College, and his colleagues suggests that my attempts at education were destined to fail. ("Effective Messages in Vaccine Promotion: A Randomized Trial," [Pediatrics 2014;133:1-8]). Aware that people frequently resist information that contradicts their views, these investigators began a small study. Nearly 1,800 parents were randomized to receive one of four messages supporting the value of MMR vaccine from textual excerpts to pictures of children with the diseases prevented by the vaccine.

What they discovered was that parents who had "mixed or negative feelings" about the vaccine were actually less likely to say that they would choose to vaccinate a future child after they had been presented with literature refuting the MMR-autism link. While these families were less likely to accept the vaccine-autism link, the informational materials had prompted them to consider other reasons that supported their negative views about vaccines.

Although other studies have found that parents still consider their children’s doctor to be the most trusted source of vaccine information, it appears that education as we understand it may not be our best tool. In fact, it may even be counterproductive. Attempts to engender fear may seem logical to us, but in reality they may be backfiring.

Dr. Nyhan and his colleagues didn’t bore down to discover what factors made a particular view so resistant to education. But, in my experience inheritance doesn’t seem to play a role. I hear from many fearful and frustrated grandparents who can’t understand why their grandchildren aren’t being immunized.

There is the hermit mentality that says by keeping apart from "all those other people" in society and by living a better life, we can protect ourselves from their diseases and don’t need immunizations. And, of course, there is the notion that even though we understand the rationale for immunization, God will protect us.

This important study suggests that we must be very thoughtful about our attempts at education in all public health issues. Our intuition has failed us here. As unfair as it may be to the child victims of this parental foolishness, we may need to fall back on strict exclusion and quarantine to protect the rest us until we learn how to convince families that they are making a serious mistake.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

Let’s be honest. Although pediatricians invest most of their days, some of their nights, and untold cockles of heartfelt concern trying to keep their patients well, there is very little evidence that what we do actually makes a difference. The one shining exception comes when we administer immunizations. This humbling fact makes the problem of vaccine refusal so frustrating and depressing.

I have always considered the increasing number of parents who refuse or who are hesitant about immunization just another example of decay in our nation’s educational system. How could anyone who was even half awake in American History class not be aware of the toll that infectious diseases took on the children born before 1900? Diseases that are now preventable. Do introductory science courses even touch on the basic mechanisms that underlie immunizations? High school students may not be expected to know that John Enders was the lead investigator in the development of the measles vaccine, but someone should have told them the story of Jonas Salk and polio.

Like many of you, I assumed that if I could just do a better job of filling in the gaps in our educational system that vaccine-hesitant parents would see the light. If I could share with parents even a small fraction of what I know about the efficacy of vaccines they couldn’t possibly refuse to immunize their children. However, after 40 years of failed attempts and frustration, I have begun to doubt my communication skills.

Some work by Brendan Nyhan, Ph.D., a government professor at Dartmouth College, and his colleagues suggests that my attempts at education were destined to fail. ("Effective Messages in Vaccine Promotion: A Randomized Trial," [Pediatrics 2014;133:1-8]). Aware that people frequently resist information that contradicts their views, these investigators began a small study. Nearly 1,800 parents were randomized to receive one of four messages supporting the value of MMR vaccine from textual excerpts to pictures of children with the diseases prevented by the vaccine.

What they discovered was that parents who had "mixed or negative feelings" about the vaccine were actually less likely to say that they would choose to vaccinate a future child after they had been presented with literature refuting the MMR-autism link. While these families were less likely to accept the vaccine-autism link, the informational materials had prompted them to consider other reasons that supported their negative views about vaccines.

Although other studies have found that parents still consider their children’s doctor to be the most trusted source of vaccine information, it appears that education as we understand it may not be our best tool. In fact, it may even be counterproductive. Attempts to engender fear may seem logical to us, but in reality they may be backfiring.

Dr. Nyhan and his colleagues didn’t bore down to discover what factors made a particular view so resistant to education. But, in my experience inheritance doesn’t seem to play a role. I hear from many fearful and frustrated grandparents who can’t understand why their grandchildren aren’t being immunized.

There is the hermit mentality that says by keeping apart from "all those other people" in society and by living a better life, we can protect ourselves from their diseases and don’t need immunizations. And, of course, there is the notion that even though we understand the rationale for immunization, God will protect us.

This important study suggests that we must be very thoughtful about our attempts at education in all public health issues. Our intuition has failed us here. As unfair as it may be to the child victims of this parental foolishness, we may need to fall back on strict exclusion and quarantine to protect the rest us until we learn how to convince families that they are making a serious mistake.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

Actually the complete phrase is "vox clamantis in deserto," and it is the motto of my alma mater. We were told as freshmen that it translated as "a voice crying in the wilderness" – which prior to the Internet, cheap long distance rates, and Interstate 89 seemed to be an apt description of my situation. The words resurfaced in my consciousness a few months ago when I met one of the regular readers of this column. A man of my vintage, he observed that over the 40-plus years he had been in practice, parents had grown increasingly less interested in his views on health and child rearing. He asked if I had experienced the same phenomenon.

In other words, he wondered if we both had become just voices crying in the wilderness. As we discussed his observation in more depth, it became clear that he wasn’t talking about the age-old phenomenon in which young people begin to tune out their elders who have persisted in palavering the same old "when-I-was-your-age" bologna. No, his question was more general. Is anyone listening to what pediatricians of any age are saying? Are our opinions less valued than they were 40 years ago? If our audience is less attentive, then why?

I agree that it does feel like, over the last 40 years, parents are less influenced by our opinions and are using increasing amounts of salt when they do listen. One only needs to consider the issue of vaccine refusal to appreciate that our advice often goes unheeded with potentially dangerous consequences.

Is the muting of our voices simply an example of dilution? Fifty years ago, pediatricians didn’t have much competition for the ears of new parents. There were Ben Spock and the always to be reckoned with army of grandmothers. Yes, there were magazines for parents, but they paled in comparison to the profusion of websites, blogs, and chat rooms that offer advice of varying quality just a mouse click away. Now we share the stage with anyone who cares to venture an opinion on health or parenting. No wonder we have trouble having our voices heard over the cacophony.

But, the din from the media is only part of the problem. I’m not sure exactly why, but over the last several decades, science has lost its mojo. Some of it has to do with the ease with which junk science can find an audience. Some of it is fallout from an educational system that is trying to regain its legs. While a good physician is more of an artist than a scientist, we were all trained as scientists. And, the public sees us as scientists, and as such, we are vulnerable to being painted with the same broad brush strokes of the antiscience folks.

To some degree we have been guilty of diluting our own messages. The trend toward health maintenance visits that are scripted by committee has done little to encourage parents to ask the questions about which they are most concerned. If we return to a model in which the patient or the parent is in the driver’s seat, we may start hearing more questions and discover our answers are given more consideration.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

Actually the complete phrase is "vox clamantis in deserto," and it is the motto of my alma mater. We were told as freshmen that it translated as "a voice crying in the wilderness" – which prior to the Internet, cheap long distance rates, and Interstate 89 seemed to be an apt description of my situation. The words resurfaced in my consciousness a few months ago when I met one of the regular readers of this column. A man of my vintage, he observed that over the 40-plus years he had been in practice, parents had grown increasingly less interested in his views on health and child rearing. He asked if I had experienced the same phenomenon.

In other words, he wondered if we both had become just voices crying in the wilderness. As we discussed his observation in more depth, it became clear that he wasn’t talking about the age-old phenomenon in which young people begin to tune out their elders who have persisted in palavering the same old "when-I-was-your-age" bologna. No, his question was more general. Is anyone listening to what pediatricians of any age are saying? Are our opinions less valued than they were 40 years ago? If our audience is less attentive, then why?

I agree that it does feel like, over the last 40 years, parents are less influenced by our opinions and are using increasing amounts of salt when they do listen. One only needs to consider the issue of vaccine refusal to appreciate that our advice often goes unheeded with potentially dangerous consequences.

Is the muting of our voices simply an example of dilution? Fifty years ago, pediatricians didn’t have much competition for the ears of new parents. There were Ben Spock and the always to be reckoned with army of grandmothers. Yes, there were magazines for parents, but they paled in comparison to the profusion of websites, blogs, and chat rooms that offer advice of varying quality just a mouse click away. Now we share the stage with anyone who cares to venture an opinion on health or parenting. No wonder we have trouble having our voices heard over the cacophony.

But, the din from the media is only part of the problem. I’m not sure exactly why, but over the last several decades, science has lost its mojo. Some of it has to do with the ease with which junk science can find an audience. Some of it is fallout from an educational system that is trying to regain its legs. While a good physician is more of an artist than a scientist, we were all trained as scientists. And, the public sees us as scientists, and as such, we are vulnerable to being painted with the same broad brush strokes of the antiscience folks.

To some degree we have been guilty of diluting our own messages. The trend toward health maintenance visits that are scripted by committee has done little to encourage parents to ask the questions about which they are most concerned. If we return to a model in which the patient or the parent is in the driver’s seat, we may start hearing more questions and discover our answers are given more consideration.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

Actually the complete phrase is "vox clamantis in deserto," and it is the motto of my alma mater. We were told as freshmen that it translated as "a voice crying in the wilderness" – which prior to the Internet, cheap long distance rates, and Interstate 89 seemed to be an apt description of my situation. The words resurfaced in my consciousness a few months ago when I met one of the regular readers of this column. A man of my vintage, he observed that over the 40-plus years he had been in practice, parents had grown increasingly less interested in his views on health and child rearing. He asked if I had experienced the same phenomenon.

In other words, he wondered if we both had become just voices crying in the wilderness. As we discussed his observation in more depth, it became clear that he wasn’t talking about the age-old phenomenon in which young people begin to tune out their elders who have persisted in palavering the same old "when-I-was-your-age" bologna. No, his question was more general. Is anyone listening to what pediatricians of any age are saying? Are our opinions less valued than they were 40 years ago? If our audience is less attentive, then why?

I agree that it does feel like, over the last 40 years, parents are less influenced by our opinions and are using increasing amounts of salt when they do listen. One only needs to consider the issue of vaccine refusal to appreciate that our advice often goes unheeded with potentially dangerous consequences.

Is the muting of our voices simply an example of dilution? Fifty years ago, pediatricians didn’t have much competition for the ears of new parents. There were Ben Spock and the always to be reckoned with army of grandmothers. Yes, there were magazines for parents, but they paled in comparison to the profusion of websites, blogs, and chat rooms that offer advice of varying quality just a mouse click away. Now we share the stage with anyone who cares to venture an opinion on health or parenting. No wonder we have trouble having our voices heard over the cacophony.

But, the din from the media is only part of the problem. I’m not sure exactly why, but over the last several decades, science has lost its mojo. Some of it has to do with the ease with which junk science can find an audience. Some of it is fallout from an educational system that is trying to regain its legs. While a good physician is more of an artist than a scientist, we were all trained as scientists. And, the public sees us as scientists, and as such, we are vulnerable to being painted with the same broad brush strokes of the antiscience folks.

To some degree we have been guilty of diluting our own messages. The trend toward health maintenance visits that are scripted by committee has done little to encourage parents to ask the questions about which they are most concerned. If we return to a model in which the patient or the parent is in the driver’s seat, we may start hearing more questions and discover our answers are given more consideration.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

In 2002 I wrote a book that the publishers chose to title, "The Maternity Leave Breastfeeding Plan: How to Enjoy Nursing for 3 Months and Go Back to Work Guilt-Free" (Chicago: Touchstone, 2002 ). I have always believed that breast milk is the natural first food for children, and that in most situations, nursing is the best option for mothers. However, after 25 years of trying to help mothers to breastfeed, I had grown increasingly troubled that for too many young mothers, the first years of parenting were shadowed by a cloud of guilt because they had "failed" at breastfeeding.

I felt that someone needed to write a book that presented a realistic view of breastfeeding. For a variety of good and bad reasons, not every woman who gives birth can successfully breastfeed. In my book, I offered as many suggestions as I could think of for making breastfeeding work. I emphasized that prenatal preparation and planning were particularly important for creating workplace, day care, and home environments that are conducive to breastfeeding. I stressed the importance of adopting realistic schedules that would allow enough recovery time from the stresses of parenting and breastfeeding. I suggested a toolbox full of ways in which fathers could improve the chances of breastfeeding success.

Woven through the book was the attitude that breastfeeding isn’t always as easy as some advocates suggest. Despite everyone’s best efforts and planning, stuff happens. I basically said that I think breastfeeding is a good idea, and here are some suggestions that can help you achieve your goal of nursing. But, if it doesn’t work, that’s okay. You are a great mother for having tried, and your child will still love you and grow up healthy.

In the last dozen years, there has been little change in the number of women initiating and successfully breastfeeding their infants.

Data supporting the benefits of breast milk continue to trickle in at a steady rate. However, based on my own anecdotal observations, I still harbor some lingering doubts about how significant these benefits have been for my patients here in North America. A recent study by some investigators at Ohio State University supports my skepticism (Cynthia G. Colen and David Ramey. "Is breast truly best? Estimating the effects of breastfeeding on long term child health and well-being in the United States using sibling comparisons" (Soc. Sci. Med. 2014;109:55-65).

These researchers looked at the National Longitudinal Survey of Youth that contains 25 years of panel data for children aged 4-14 years. If one merely compares breastfed versus nonbreastfed children, those who were breastfed score better on 10 of the 11 outcomes included in the survey. However, when the Ohio State investigators restricted their analyses to siblings, they found that with the exception of one outcome, the differences between breastfed and nonbreastfed children were no longer statistically significant. This observation makes one wonder how many other studies that purport to support the health benefits of breastfeeding have failed to adequately control for socioeconomic and demographic influences.

So where does this leave those of us tasked with helping young women breastfeed? The fact that I first learned about this study in the New York Times suggests that we will be challenged to respond. Obviously, we should still encourage mothers to breastfeed because it appears that the attitudes and environment that prompted a mother to choose to breastfeed at least once may be as important as whether her child actually receives breast milk.

For me, this study won’t change much because I have always avoided giving parents a laundry list of the advantages of breastfeeding.

However, I will keep this study’s findings tucked away to be pulled out when a mother has lost her struggle to breastfeed. Properly used, these results could be a free pass for her to climb off the Breastfeeding Guilt Trip Express.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at pdnews@ frontlinemedcom.com. 

In 2002 I wrote a book that the publishers chose to title, "The Maternity Leave Breastfeeding Plan: How to Enjoy Nursing for 3 Months and Go Back to Work Guilt-Free" (Chicago: Touchstone, 2002 ). I have always believed that breast milk is the natural first food for children, and that in most situations, nursing is the best option for mothers. However, after 25 years of trying to help mothers to breastfeed, I had grown increasingly troubled that for too many young mothers, the first years of parenting were shadowed by a cloud of guilt because they had "failed" at breastfeeding.

I felt that someone needed to write a book that presented a realistic view of breastfeeding. For a variety of good and bad reasons, not every woman who gives birth can successfully breastfeed. In my book, I offered as many suggestions as I could think of for making breastfeeding work. I emphasized that prenatal preparation and planning were particularly important for creating workplace, day care, and home environments that are conducive to breastfeeding. I stressed the importance of adopting realistic schedules that would allow enough recovery time from the stresses of parenting and breastfeeding. I suggested a toolbox full of ways in which fathers could improve the chances of breastfeeding success.

Woven through the book was the attitude that breastfeeding isn’t always as easy as some advocates suggest. Despite everyone’s best efforts and planning, stuff happens. I basically said that I think breastfeeding is a good idea, and here are some suggestions that can help you achieve your goal of nursing. But, if it doesn’t work, that’s okay. You are a great mother for having tried, and your child will still love you and grow up healthy.

In the last dozen years, there has been little change in the number of women initiating and successfully breastfeeding their infants.

Data supporting the benefits of breast milk continue to trickle in at a steady rate. However, based on my own anecdotal observations, I still harbor some lingering doubts about how significant these benefits have been for my patients here in North America. A recent study by some investigators at Ohio State University supports my skepticism (Cynthia G. Colen and David Ramey. "Is breast truly best? Estimating the effects of breastfeeding on long term child health and well-being in the United States using sibling comparisons" (Soc. Sci. Med. 2014;109:55-65).

These researchers looked at the National Longitudinal Survey of Youth that contains 25 years of panel data for children aged 4-14 years. If one merely compares breastfed versus nonbreastfed children, those who were breastfed score better on 10 of the 11 outcomes included in the survey. However, when the Ohio State investigators restricted their analyses to siblings, they found that with the exception of one outcome, the differences between breastfed and nonbreastfed children were no longer statistically significant. This observation makes one wonder how many other studies that purport to support the health benefits of breastfeeding have failed to adequately control for socioeconomic and demographic influences.

So where does this leave those of us tasked with helping young women breastfeed? The fact that I first learned about this study in the New York Times suggests that we will be challenged to respond. Obviously, we should still encourage mothers to breastfeed because it appears that the attitudes and environment that prompted a mother to choose to breastfeed at least once may be as important as whether her child actually receives breast milk.

For me, this study won’t change much because I have always avoided giving parents a laundry list of the advantages of breastfeeding.

However, I will keep this study’s findings tucked away to be pulled out when a mother has lost her struggle to breastfeed. Properly used, these results could be a free pass for her to climb off the Breastfeeding Guilt Trip Express.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at pdnews@ frontlinemedcom.com. 

In 2002 I wrote a book that the publishers chose to title, "The Maternity Leave Breastfeeding Plan: How to Enjoy Nursing for 3 Months and Go Back to Work Guilt-Free" (Chicago: Touchstone, 2002 ). I have always believed that breast milk is the natural first food for children, and that in most situations, nursing is the best option for mothers. However, after 25 years of trying to help mothers to breastfeed, I had grown increasingly troubled that for too many young mothers, the first years of parenting were shadowed by a cloud of guilt because they had "failed" at breastfeeding.

I felt that someone needed to write a book that presented a realistic view of breastfeeding. For a variety of good and bad reasons, not every woman who gives birth can successfully breastfeed. In my book, I offered as many suggestions as I could think of for making breastfeeding work. I emphasized that prenatal preparation and planning were particularly important for creating workplace, day care, and home environments that are conducive to breastfeeding. I stressed the importance of adopting realistic schedules that would allow enough recovery time from the stresses of parenting and breastfeeding. I suggested a toolbox full of ways in which fathers could improve the chances of breastfeeding success.

Woven through the book was the attitude that breastfeeding isn’t always as easy as some advocates suggest. Despite everyone’s best efforts and planning, stuff happens. I basically said that I think breastfeeding is a good idea, and here are some suggestions that can help you achieve your goal of nursing. But, if it doesn’t work, that’s okay. You are a great mother for having tried, and your child will still love you and grow up healthy.

In the last dozen years, there has been little change in the number of women initiating and successfully breastfeeding their infants.

Data supporting the benefits of breast milk continue to trickle in at a steady rate. However, based on my own anecdotal observations, I still harbor some lingering doubts about how significant these benefits have been for my patients here in North America. A recent study by some investigators at Ohio State University supports my skepticism (Cynthia G. Colen and David Ramey. "Is breast truly best? Estimating the effects of breastfeeding on long term child health and well-being in the United States using sibling comparisons" (Soc. Sci. Med. 2014;109:55-65).

These researchers looked at the National Longitudinal Survey of Youth that contains 25 years of panel data for children aged 4-14 years. If one merely compares breastfed versus nonbreastfed children, those who were breastfed score better on 10 of the 11 outcomes included in the survey. However, when the Ohio State investigators restricted their analyses to siblings, they found that with the exception of one outcome, the differences between breastfed and nonbreastfed children were no longer statistically significant. This observation makes one wonder how many other studies that purport to support the health benefits of breastfeeding have failed to adequately control for socioeconomic and demographic influences.

So where does this leave those of us tasked with helping young women breastfeed? The fact that I first learned about this study in the New York Times suggests that we will be challenged to respond. Obviously, we should still encourage mothers to breastfeed because it appears that the attitudes and environment that prompted a mother to choose to breastfeed at least once may be as important as whether her child actually receives breast milk.

For me, this study won’t change much because I have always avoided giving parents a laundry list of the advantages of breastfeeding.

However, I will keep this study’s findings tucked away to be pulled out when a mother has lost her struggle to breastfeed. Properly used, these results could be a free pass for her to climb off the Breastfeeding Guilt Trip Express.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at pdnews@ frontlinemedcom.com. 

Marketing consultants have known it for years. Packaging sells the product. Putting it in the right color box can make the difference between a top seller and a flop. The truth is that most of us select wine by the appearance of the label and books by the design on the jacket.

In medicine, we package signs and symptoms in diagnoses and syndromes, and sometimes add an extra label that says "disease" in bold letters. But, what qualifies a particular constellation of physical findings and patients’ complaints as a "disease"?

This is not a trivial question. For the unfortunate victims, having a "disease" may allow them to tell their friends, "See, I’m not just a whiner. I actually have something. I have a disease." Diseases sometimes have their own specialists. Some have support groups, fund-raising foundations, and spokespersons.

In June 2013, the American Medical Association took the bold step of labeling obesity a "multimetabolic and hormonal disease state." This was the next logical step in an evolution that began with parents being told that their children would outgrow their baby fat if they adjusted their diets. Now we know that the seeds of obesity may be planted well before birth, and have certainly taken firm root before age 3 years to persist as a chronic condition with a myriad of life-altering ramifications. Sounds like a "disease" to me.

In an article in a New York Times Sunday Review, two psychologists from the University of Richmond discuss the dilemmas associated with this repackaging of obesity as a "disease" ("Should Obesity Be a Disease?" Crystal L. Hoyt and Jeni L. Burnette. Feb. 21, 2014). With a colleague from the University of Minnesota, these researchers performed three studies with 700 subjects who were divided into two groups. One group was given an article from a family magazine that included the standard advice on setting weight management goals. The other was provided an article clearly stating that obesity is a disease.

Surveys of the two groups revealed that for the obese individuals, reading the obesity is a disease article improved their "body satisfaction." Not a surprise. Nor is the observation that the same message made attempts at change seem futile. Another of their studies showed that this attitude of futility was correlated with less-healthy, higher-calorie food choices.

So it appears that in labeling obesity as a disease, the AMA has handed us a double-edged sword. We can use the new packaging to help our obese patients feel better about themselves. But, we must be prepared to address a sense of futility that may accompany their acceptance of a disease for which we currently don’t have a cure. Faced with this dilemma, we may need to adopt the style of successful chronic disease specialists. Sharing our frustration, we must remind our obese patients that while we don’t have a cure, we can help them manage their disease in a way that minimizes its ill effects.

While the disease label can cut both ways for our current patients, we should seize the opportunity to use it as a potent weapon in prevention for our patients yet to be born or even conceived. And, now we understand that prevention means taking aggressive steps prenatally and in the first 2 years of life before it’s too late. Armed with the new label, it is time to mount a serious campaign with the slogan, "Baby Fat is a Preventable Disease!"

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

Marketing consultants have known it for years. Packaging sells the product. Putting it in the right color box can make the difference between a top seller and a flop. The truth is that most of us select wine by the appearance of the label and books by the design on the jacket.

In medicine, we package signs and symptoms in diagnoses and syndromes, and sometimes add an extra label that says "disease" in bold letters. But, what qualifies a particular constellation of physical findings and patients’ complaints as a "disease"?

This is not a trivial question. For the unfortunate victims, having a "disease" may allow them to tell their friends, "See, I’m not just a whiner. I actually have something. I have a disease." Diseases sometimes have their own specialists. Some have support groups, fund-raising foundations, and spokespersons.

In June 2013, the American Medical Association took the bold step of labeling obesity a "multimetabolic and hormonal disease state." This was the next logical step in an evolution that began with parents being told that their children would outgrow their baby fat if they adjusted their diets. Now we know that the seeds of obesity may be planted well before birth, and have certainly taken firm root before age 3 years to persist as a chronic condition with a myriad of life-altering ramifications. Sounds like a "disease" to me.

In an article in a New York Times Sunday Review, two psychologists from the University of Richmond discuss the dilemmas associated with this repackaging of obesity as a "disease" ("Should Obesity Be a Disease?" Crystal L. Hoyt and Jeni L. Burnette. Feb. 21, 2014). With a colleague from the University of Minnesota, these researchers performed three studies with 700 subjects who were divided into two groups. One group was given an article from a family magazine that included the standard advice on setting weight management goals. The other was provided an article clearly stating that obesity is a disease.

Surveys of the two groups revealed that for the obese individuals, reading the obesity is a disease article improved their "body satisfaction." Not a surprise. Nor is the observation that the same message made attempts at change seem futile. Another of their studies showed that this attitude of futility was correlated with less-healthy, higher-calorie food choices.

So it appears that in labeling obesity as a disease, the AMA has handed us a double-edged sword. We can use the new packaging to help our obese patients feel better about themselves. But, we must be prepared to address a sense of futility that may accompany their acceptance of a disease for which we currently don’t have a cure. Faced with this dilemma, we may need to adopt the style of successful chronic disease specialists. Sharing our frustration, we must remind our obese patients that while we don’t have a cure, we can help them manage their disease in a way that minimizes its ill effects.

While the disease label can cut both ways for our current patients, we should seize the opportunity to use it as a potent weapon in prevention for our patients yet to be born or even conceived. And, now we understand that prevention means taking aggressive steps prenatally and in the first 2 years of life before it’s too late. Armed with the new label, it is time to mount a serious campaign with the slogan, "Baby Fat is a Preventable Disease!"

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

Marketing consultants have known it for years. Packaging sells the product. Putting it in the right color box can make the difference between a top seller and a flop. The truth is that most of us select wine by the appearance of the label and books by the design on the jacket.

In medicine, we package signs and symptoms in diagnoses and syndromes, and sometimes add an extra label that says "disease" in bold letters. But, what qualifies a particular constellation of physical findings and patients’ complaints as a "disease"?

This is not a trivial question. For the unfortunate victims, having a "disease" may allow them to tell their friends, "See, I’m not just a whiner. I actually have something. I have a disease." Diseases sometimes have their own specialists. Some have support groups, fund-raising foundations, and spokespersons.

In June 2013, the American Medical Association took the bold step of labeling obesity a "multimetabolic and hormonal disease state." This was the next logical step in an evolution that began with parents being told that their children would outgrow their baby fat if they adjusted their diets. Now we know that the seeds of obesity may be planted well before birth, and have certainly taken firm root before age 3 years to persist as a chronic condition with a myriad of life-altering ramifications. Sounds like a "disease" to me.

In an article in a New York Times Sunday Review, two psychologists from the University of Richmond discuss the dilemmas associated with this repackaging of obesity as a "disease" ("Should Obesity Be a Disease?" Crystal L. Hoyt and Jeni L. Burnette. Feb. 21, 2014). With a colleague from the University of Minnesota, these researchers performed three studies with 700 subjects who were divided into two groups. One group was given an article from a family magazine that included the standard advice on setting weight management goals. The other was provided an article clearly stating that obesity is a disease.

Surveys of the two groups revealed that for the obese individuals, reading the obesity is a disease article improved their "body satisfaction." Not a surprise. Nor is the observation that the same message made attempts at change seem futile. Another of their studies showed that this attitude of futility was correlated with less-healthy, higher-calorie food choices.

So it appears that in labeling obesity as a disease, the AMA has handed us a double-edged sword. We can use the new packaging to help our obese patients feel better about themselves. But, we must be prepared to address a sense of futility that may accompany their acceptance of a disease for which we currently don’t have a cure. Faced with this dilemma, we may need to adopt the style of successful chronic disease specialists. Sharing our frustration, we must remind our obese patients that while we don’t have a cure, we can help them manage their disease in a way that minimizes its ill effects.

While the disease label can cut both ways for our current patients, we should seize the opportunity to use it as a potent weapon in prevention for our patients yet to be born or even conceived. And, now we understand that prevention means taking aggressive steps prenatally and in the first 2 years of life before it’s too late. Armed with the new label, it is time to mount a serious campaign with the slogan, "Baby Fat is a Preventable Disease!"

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

Ouppfostrade ... Is it a) The sound of a pendulum that has swung too far to the left? Or is it b) a Swedish word that means "badly raised children"?

As I learned in a Wall Street Journal article, the correct answer is b ("Badly Raised Kids? Sweden Has a Word for That," Jens Hansegard, Feb. 11, 2014).

In the opinion of Dr. David Eberhard, a Swedish psychiatrist, decades of child-centric policies have "gone too far" and the result is a nation of poorly raised children who may be more vulnerable to anxiety and depression as they grow older.

Dr. Eberhard, who is also the father of six, freely admits that his conclusions are based on "common sense" and observations that are not the result of scientific studies. However, his opinions have touched a sympathetic nerve with more than a few of his fellow countrymen. Although most newspaper editorials have been critical of his ideas, blogs are divided 50/50. Apparently, there are plenty of Swedes who feel that new millennium parents are spineless wimps being pushed around by their children. Dr. Eberhard’s critics counter that Sweden’s reputation for innovation in a broad variety of fields and its enviable happiness rating are in part the result of its policies empowering children.

Does any of this parenting brouhaha strike a familiar chord? Or, is the issue of poorly disciplined children a uniquely Swedish phenomenon? The United States has certainly not enacted as many robust child-centric policies as Sweden and her Scandinavian sisters have. But, while critics have little cause to blame the government, one certainly feels a rumbling of discontent in some circles that America has an overabundance of poorly disciplined children. It is tempting to assume that most of the grumbling is coming from grandparents and their peers in the form of "when-I-was-your-age" rhetoric. But I think there are enough young parents who feel that they have lost (if they ever had) control of the situation that it is an issue worth considering by pediatricians.

As in Sweden, the situation is probably the result of generational drift in which today’s children are being parented by parents whose parents and even grandparents were uncomfortable saying "no." Without solid role models and without a cultural tradition to follow, many modern parents are adrift. Blown in one direction by "experts" with overly child-centric advice and pushed in another by a vocal minority who advocate an authoritarian style, parents can be paralyzed by the fear of doing it all wrong. So they don’t do anything about creating structure and discipline.

Most parents know that spanking is wrong, but they aren’t sure what strategy they should use when their child misbehaves. They may have tried time-out, but for a variety of reasons it didn’t work. Some parents may have trouble overcoming a nagging feeling of guilt that they have to leave their children in day care. Once home, it is hard for a working parent, in fact any parent, to be a friend to the child, and still be the person who makes the rules and metes out the consequences. And, of course, there are a few parents who even question whether there should be any rules for children.

Fortunately, the examples of extreme child-centricity are rare. Most of the time, parents are eager to hear parenting advice from their pediatricians. However, it is up to the pediatrician to make it clear that she or he is interested in the everyday behavior issues, such as saying "no." Pediatricians must be prepared to offer advice that is based on their knowledge of normal child development and not tilted toward either extreme. But, this kind of counseling takes time. To help parents develop a system of limits and consequences that is appropriate for their child’s temperament and developmental age can’t be done in a 10-minute visit. But, first, pediatricians must make it clear that we aren’t just the ear infection folks. We have the skills and experience to deal with ouppfostrade before it becomes epidemic here in America.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including, "How to Say No to Your Toddler." E-mail him at [email protected].

Ouppfostrade ... Is it a) The sound of a pendulum that has swung too far to the left? Or is it b) a Swedish word that means "badly raised children"?

As I learned in a Wall Street Journal article, the correct answer is b ("Badly Raised Kids? Sweden Has a Word for That," Jens Hansegard, Feb. 11, 2014).

In the opinion of Dr. David Eberhard, a Swedish psychiatrist, decades of child-centric policies have "gone too far" and the result is a nation of poorly raised children who may be more vulnerable to anxiety and depression as they grow older.

Dr. Eberhard, who is also the father of six, freely admits that his conclusions are based on "common sense" and observations that are not the result of scientific studies. However, his opinions have touched a sympathetic nerve with more than a few of his fellow countrymen. Although most newspaper editorials have been critical of his ideas, blogs are divided 50/50. Apparently, there are plenty of Swedes who feel that new millennium parents are spineless wimps being pushed around by their children. Dr. Eberhard’s critics counter that Sweden’s reputation for innovation in a broad variety of fields and its enviable happiness rating are in part the result of its policies empowering children.

Does any of this parenting brouhaha strike a familiar chord? Or, is the issue of poorly disciplined children a uniquely Swedish phenomenon? The United States has certainly not enacted as many robust child-centric policies as Sweden and her Scandinavian sisters have. But, while critics have little cause to blame the government, one certainly feels a rumbling of discontent in some circles that America has an overabundance of poorly disciplined children. It is tempting to assume that most of the grumbling is coming from grandparents and their peers in the form of "when-I-was-your-age" rhetoric. But I think there are enough young parents who feel that they have lost (if they ever had) control of the situation that it is an issue worth considering by pediatricians.

As in Sweden, the situation is probably the result of generational drift in which today’s children are being parented by parents whose parents and even grandparents were uncomfortable saying "no." Without solid role models and without a cultural tradition to follow, many modern parents are adrift. Blown in one direction by "experts" with overly child-centric advice and pushed in another by a vocal minority who advocate an authoritarian style, parents can be paralyzed by the fear of doing it all wrong. So they don’t do anything about creating structure and discipline.

Most parents know that spanking is wrong, but they aren’t sure what strategy they should use when their child misbehaves. They may have tried time-out, but for a variety of reasons it didn’t work. Some parents may have trouble overcoming a nagging feeling of guilt that they have to leave their children in day care. Once home, it is hard for a working parent, in fact any parent, to be a friend to the child, and still be the person who makes the rules and metes out the consequences. And, of course, there are a few parents who even question whether there should be any rules for children.

Fortunately, the examples of extreme child-centricity are rare. Most of the time, parents are eager to hear parenting advice from their pediatricians. However, it is up to the pediatrician to make it clear that she or he is interested in the everyday behavior issues, such as saying "no." Pediatricians must be prepared to offer advice that is based on their knowledge of normal child development and not tilted toward either extreme. But, this kind of counseling takes time. To help parents develop a system of limits and consequences that is appropriate for their child’s temperament and developmental age can’t be done in a 10-minute visit. But, first, pediatricians must make it clear that we aren’t just the ear infection folks. We have the skills and experience to deal with ouppfostrade before it becomes epidemic here in America.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including, "How to Say No to Your Toddler." E-mail him at [email protected].

Ouppfostrade ... Is it a) The sound of a pendulum that has swung too far to the left? Or is it b) a Swedish word that means "badly raised children"?

As I learned in a Wall Street Journal article, the correct answer is b ("Badly Raised Kids? Sweden Has a Word for That," Jens Hansegard, Feb. 11, 2014).

In the opinion of Dr. David Eberhard, a Swedish psychiatrist, decades of child-centric policies have "gone too far" and the result is a nation of poorly raised children who may be more vulnerable to anxiety and depression as they grow older.

Dr. Eberhard, who is also the father of six, freely admits that his conclusions are based on "common sense" and observations that are not the result of scientific studies. However, his opinions have touched a sympathetic nerve with more than a few of his fellow countrymen. Although most newspaper editorials have been critical of his ideas, blogs are divided 50/50. Apparently, there are plenty of Swedes who feel that new millennium parents are spineless wimps being pushed around by their children. Dr. Eberhard’s critics counter that Sweden’s reputation for innovation in a broad variety of fields and its enviable happiness rating are in part the result of its policies empowering children.

Does any of this parenting brouhaha strike a familiar chord? Or, is the issue of poorly disciplined children a uniquely Swedish phenomenon? The United States has certainly not enacted as many robust child-centric policies as Sweden and her Scandinavian sisters have. But, while critics have little cause to blame the government, one certainly feels a rumbling of discontent in some circles that America has an overabundance of poorly disciplined children. It is tempting to assume that most of the grumbling is coming from grandparents and their peers in the form of "when-I-was-your-age" rhetoric. But I think there are enough young parents who feel that they have lost (if they ever had) control of the situation that it is an issue worth considering by pediatricians.

As in Sweden, the situation is probably the result of generational drift in which today’s children are being parented by parents whose parents and even grandparents were uncomfortable saying "no." Without solid role models and without a cultural tradition to follow, many modern parents are adrift. Blown in one direction by "experts" with overly child-centric advice and pushed in another by a vocal minority who advocate an authoritarian style, parents can be paralyzed by the fear of doing it all wrong. So they don’t do anything about creating structure and discipline.

Most parents know that spanking is wrong, but they aren’t sure what strategy they should use when their child misbehaves. They may have tried time-out, but for a variety of reasons it didn’t work. Some parents may have trouble overcoming a nagging feeling of guilt that they have to leave their children in day care. Once home, it is hard for a working parent, in fact any parent, to be a friend to the child, and still be the person who makes the rules and metes out the consequences. And, of course, there are a few parents who even question whether there should be any rules for children.

Fortunately, the examples of extreme child-centricity are rare. Most of the time, parents are eager to hear parenting advice from their pediatricians. However, it is up to the pediatrician to make it clear that she or he is interested in the everyday behavior issues, such as saying "no." Pediatricians must be prepared to offer advice that is based on their knowledge of normal child development and not tilted toward either extreme. But, this kind of counseling takes time. To help parents develop a system of limits and consequences that is appropriate for their child’s temperament and developmental age can’t be done in a 10-minute visit. But, first, pediatricians must make it clear that we aren’t just the ear infection folks. We have the skills and experience to deal with ouppfostrade before it becomes epidemic here in America.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including, "How to Say No to Your Toddler." E-mail him at [email protected].

I’m willing to give the Affordable Care Act several more months before I finally decide that it is as poorly conceived and executed as it appears to be at the moment. However, when it comes to the efforts by the federal government to speed the adoption of electronic health records, I’m sure that the result has been several giant steps backward for both the quality of medical care and the level of satisfaction for the physicians in this country.

Doctors who have begun to use electronic health records (EHRs) are finding that they are spending more hours of their day in front of a computer screen doing clerical work. If they can’t afford to see fewer patients, the result is an extra hour or two at the end of the day catching up with the paperless work. This means that hours of family and rejuvenation time that were already in short supply are lost. A recent survey by Mark William Friedberg of the Rand Corp. and his associates listed the burden caused by electronic health records as the leading contributor to physician dissatisfaction. Neither physicians nor their patients are happy with the loss of eye to eye contact that also accompanies the adoption of EHRs.

I suspect that most physicians continue to hold out hope that computerized medical records will prove to benefit patient care in the long run. But, their patience has worn so thin it is easy to see the frustration on their faces and hear it in their voices. Those of us who have already endured more than once the steep learning curve that comes with a new computer system have found that at the top of the curve is a plateau – a plateau that leaves us no more productive than we were when we started the painful and expensive climb, despite promises from the vendors and administrators who bought their sales pitches.

But, there may be a solution to at least some of the downside to electronic health records, namely, scribes. A scribe is an assistant who accompanies the physician as he sees patients and records the pertinent information generated from the visit in real time. The result is a completed medical record and a bill for services without the physician having to lift a pen, move a cursor, or take her eyes off the patient. It is estimated that there are nearly 10,000 scribes working in this country, and there are companies who promise to provide a turnkey operation that includes hiring, training, and updating skills. The charge for the service runs about $20-$25 per hour, with the scribe receiving $8-$16 per hour.

Scribes have been most popular in hospitals and emergency departments where the expense may be less of a hurdle than elsewhere, but they work in outpatient settings as well. The issue of confidentiality has been raised, but it doesn’t seem to have been a problem. Patients are accustomed to having a nurse or chaperone, and for many years haven’t expressed much concern about having their medical records read or listened to by transcriptionists.

If I were still in practice, I think I could easily rationalize the cost of a scribe if he or she allowed me to get home an hour or two earlier. I suspect my children would even have been willing to chip in some of their allowance to fund the service if it allowed their father to show up for dinner and in a sunnier frame of mind.

Two little wrinkles come to mind, but I think they could be easily ironed out. My exam rooms have never been terribly spacious, and now that two parents and a grandparent often accompany the patient, I wonder where we would put another warm body. And, with the increasing volume of mental health–related visits that pediatricians are seeing, I can imagine a few situations in which the presence of a scribe might be a deterrent to effective communication. However, I am sure that it would be easy to arrange a system in which the physician wore a microphone that would connect to the scribe in another room. A prominently displayed sign reminding the patient that a scribe was listening and recording would blend in with the other informational signs that paper the walls of most examining rooms and are being ignored.

So what do you think? Would a scribe system work for you? Would it be worth the expense? Can you imagine some downsides that I haven’t considered?

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at pdnews@ frontlinemedcom.com. Scan this QR code or go to pediatricnews.com to read similar columns.

I’m willing to give the Affordable Care Act several more months before I finally decide that it is as poorly conceived and executed as it appears to be at the moment. However, when it comes to the efforts by the federal government to speed the adoption of electronic health records, I’m sure that the result has been several giant steps backward for both the quality of medical care and the level of satisfaction for the physicians in this country.

Doctors who have begun to use electronic health records (EHRs) are finding that they are spending more hours of their day in front of a computer screen doing clerical work. If they can’t afford to see fewer patients, the result is an extra hour or two at the end of the day catching up with the paperless work. This means that hours of family and rejuvenation time that were already in short supply are lost. A recent survey by Mark William Friedberg of the Rand Corp. and his associates listed the burden caused by electronic health records as the leading contributor to physician dissatisfaction. Neither physicians nor their patients are happy with the loss of eye to eye contact that also accompanies the adoption of EHRs.

I suspect that most physicians continue to hold out hope that computerized medical records will prove to benefit patient care in the long run. But, their patience has worn so thin it is easy to see the frustration on their faces and hear it in their voices. Those of us who have already endured more than once the steep learning curve that comes with a new computer system have found that at the top of the curve is a plateau – a plateau that leaves us no more productive than we were when we started the painful and expensive climb, despite promises from the vendors and administrators who bought their sales pitches.

But, there may be a solution to at least some of the downside to electronic health records, namely, scribes. A scribe is an assistant who accompanies the physician as he sees patients and records the pertinent information generated from the visit in real time. The result is a completed medical record and a bill for services without the physician having to lift a pen, move a cursor, or take her eyes off the patient. It is estimated that there are nearly 10,000 scribes working in this country, and there are companies who promise to provide a turnkey operation that includes hiring, training, and updating skills. The charge for the service runs about $20-$25 per hour, with the scribe receiving $8-$16 per hour.

Scribes have been most popular in hospitals and emergency departments where the expense may be less of a hurdle than elsewhere, but they work in outpatient settings as well. The issue of confidentiality has been raised, but it doesn’t seem to have been a problem. Patients are accustomed to having a nurse or chaperone, and for many years haven’t expressed much concern about having their medical records read or listened to by transcriptionists.

If I were still in practice, I think I could easily rationalize the cost of a scribe if he or she allowed me to get home an hour or two earlier. I suspect my children would even have been willing to chip in some of their allowance to fund the service if it allowed their father to show up for dinner and in a sunnier frame of mind.

Two little wrinkles come to mind, but I think they could be easily ironed out. My exam rooms have never been terribly spacious, and now that two parents and a grandparent often accompany the patient, I wonder where we would put another warm body. And, with the increasing volume of mental health–related visits that pediatricians are seeing, I can imagine a few situations in which the presence of a scribe might be a deterrent to effective communication. However, I am sure that it would be easy to arrange a system in which the physician wore a microphone that would connect to the scribe in another room. A prominently displayed sign reminding the patient that a scribe was listening and recording would blend in with the other informational signs that paper the walls of most examining rooms and are being ignored.

So what do you think? Would a scribe system work for you? Would it be worth the expense? Can you imagine some downsides that I haven’t considered?

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at pdnews@ frontlinemedcom.com. Scan this QR code or go to pediatricnews.com to read similar columns.

I’m willing to give the Affordable Care Act several more months before I finally decide that it is as poorly conceived and executed as it appears to be at the moment. However, when it comes to the efforts by the federal government to speed the adoption of electronic health records, I’m sure that the result has been several giant steps backward for both the quality of medical care and the level of satisfaction for the physicians in this country.

Doctors who have begun to use electronic health records (EHRs) are finding that they are spending more hours of their day in front of a computer screen doing clerical work. If they can’t afford to see fewer patients, the result is an extra hour or two at the end of the day catching up with the paperless work. This means that hours of family and rejuvenation time that were already in short supply are lost. A recent survey by Mark William Friedberg of the Rand Corp. and his associates listed the burden caused by electronic health records as the leading contributor to physician dissatisfaction. Neither physicians nor their patients are happy with the loss of eye to eye contact that also accompanies the adoption of EHRs.

I suspect that most physicians continue to hold out hope that computerized medical records will prove to benefit patient care in the long run. But, their patience has worn so thin it is easy to see the frustration on their faces and hear it in their voices. Those of us who have already endured more than once the steep learning curve that comes with a new computer system have found that at the top of the curve is a plateau – a plateau that leaves us no more productive than we were when we started the painful and expensive climb, despite promises from the vendors and administrators who bought their sales pitches.

But, there may be a solution to at least some of the downside to electronic health records, namely, scribes. A scribe is an assistant who accompanies the physician as he sees patients and records the pertinent information generated from the visit in real time. The result is a completed medical record and a bill for services without the physician having to lift a pen, move a cursor, or take her eyes off the patient. It is estimated that there are nearly 10,000 scribes working in this country, and there are companies who promise to provide a turnkey operation that includes hiring, training, and updating skills. The charge for the service runs about $20-$25 per hour, with the scribe receiving $8-$16 per hour.

Scribes have been most popular in hospitals and emergency departments where the expense may be less of a hurdle than elsewhere, but they work in outpatient settings as well. The issue of confidentiality has been raised, but it doesn’t seem to have been a problem. Patients are accustomed to having a nurse or chaperone, and for many years haven’t expressed much concern about having their medical records read or listened to by transcriptionists.

If I were still in practice, I think I could easily rationalize the cost of a scribe if he or she allowed me to get home an hour or two earlier. I suspect my children would even have been willing to chip in some of their allowance to fund the service if it allowed their father to show up for dinner and in a sunnier frame of mind.

Two little wrinkles come to mind, but I think they could be easily ironed out. My exam rooms have never been terribly spacious, and now that two parents and a grandparent often accompany the patient, I wonder where we would put another warm body. And, with the increasing volume of mental health–related visits that pediatricians are seeing, I can imagine a few situations in which the presence of a scribe might be a deterrent to effective communication. However, I am sure that it would be easy to arrange a system in which the physician wore a microphone that would connect to the scribe in another room. A prominently displayed sign reminding the patient that a scribe was listening and recording would blend in with the other informational signs that paper the walls of most examining rooms and are being ignored.

So what do you think? Would a scribe system work for you? Would it be worth the expense? Can you imagine some downsides that I haven’t considered?

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at pdnews@ frontlinemedcom.com. Scan this QR code or go to pediatricnews.com to read similar columns.

I recently received an e-mail from a pediatrician who described the awkward situation in her community in which many of the other pediatricians don’t include a genital exam as part of their complete physicals.

While patients who have grown up in her practice expect a complete exam, new patients or the patients of other physicians for whom she is covering are surprised. And, it is usually not a pleasant surprise. I assume she doesn’t force the issue, but I am sure that the differing expectations cast an uncomfortable cloud over the clinical encounter.

This is an unpleasant experience that I have shared with her on more than several occasions. Again, the usual scenario is a new patient who has come from "away"(as we say here in Maine). They may already be skeptical about whether any of us here in the North Country ever finished high school and harbor the unspoken concern that "Vacation Land" is a place that attracts sexual deviants.

As much as we would like to present ourselves as scientists, physicians are no less immune to ambivalence and discomfort with issues of a sexual nature. None of us likes to have our genitals examined regardless of the sex of the examiner, and, most of us have a lingering discomfort being the examiner. I suspect that in large part this discomfort is the result of our concerns about what the examinee and his or her parents are thinking.

This doctor’s e-mail raises at least two issues. First, it is another example of the value of continuity. The young patient who has had his or her genitals examined by the same physician at multiple visits over the course of years is less likely to feel uncomfortable about the process, and this comfort level may delay the inevitable onset of the modesty years.

The bigger issue is really a collection of questions. Should pediatricians include a genital exam when they do complete physicals? The obvious and politically correct answer is "yes." But, my correspondent’s experience and my own say that it isn’t happening. As an example, I have often seen 9-month-old girls with nearly complete labial fusion who have been examined multiple times by other physicians. We can argue about whether there is anything we should do about labial fusion, but the bottom line is that no one was looking for it. Do you share our observations about this inconsistency?

What does constitute a genital exam in a 7-year-old? And, what is its value? I don’t have the answers, but I will share my thoughts. I suspect that a hands-off visual inspection is enough most of the time. Is there pubic hair? Do you see two testicles? Does the penis appear normal in size? This kind of an examination takes seconds and doesn’t require a total strip down. But, it would appear that even this briefest of looks isn’t getting done as often as it should.

So, the biggest question is what should be done about this kind of doctor-to-doctor inconsistency? Is it worth doing anything about? It is certainly creating some discomfort for physicians who have to explain and defend their practices to patients they have never met before. Is it an issue for the American Academy of Pediatrics to tackle? Should it be a topic for state chapters or local pediatric societies to address? Or, should it just be kept as a topic for physician-to-physician discussions in group practices?

I will be interested to hear what you all think about venturing into the nether regions.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at pdnews@ frontlinemedcom.com.

I recently received an e-mail from a pediatrician who described the awkward situation in her community in which many of the other pediatricians don’t include a genital exam as part of their complete physicals.

While patients who have grown up in her practice expect a complete exam, new patients or the patients of other physicians for whom she is covering are surprised. And, it is usually not a pleasant surprise. I assume she doesn’t force the issue, but I am sure that the differing expectations cast an uncomfortable cloud over the clinical encounter.

This is an unpleasant experience that I have shared with her on more than several occasions. Again, the usual scenario is a new patient who has come from "away"(as we say here in Maine). They may already be skeptical about whether any of us here in the North Country ever finished high school and harbor the unspoken concern that "Vacation Land" is a place that attracts sexual deviants.

As much as we would like to present ourselves as scientists, physicians are no less immune to ambivalence and discomfort with issues of a sexual nature. None of us likes to have our genitals examined regardless of the sex of the examiner, and, most of us have a lingering discomfort being the examiner. I suspect that in large part this discomfort is the result of our concerns about what the examinee and his or her parents are thinking.

This doctor’s e-mail raises at least two issues. First, it is another example of the value of continuity. The young patient who has had his or her genitals examined by the same physician at multiple visits over the course of years is less likely to feel uncomfortable about the process, and this comfort level may delay the inevitable onset of the modesty years.

The bigger issue is really a collection of questions. Should pediatricians include a genital exam when they do complete physicals? The obvious and politically correct answer is "yes." But, my correspondent’s experience and my own say that it isn’t happening. As an example, I have often seen 9-month-old girls with nearly complete labial fusion who have been examined multiple times by other physicians. We can argue about whether there is anything we should do about labial fusion, but the bottom line is that no one was looking for it. Do you share our observations about this inconsistency?

What does constitute a genital exam in a 7-year-old? And, what is its value? I don’t have the answers, but I will share my thoughts. I suspect that a hands-off visual inspection is enough most of the time. Is there pubic hair? Do you see two testicles? Does the penis appear normal in size? This kind of an examination takes seconds and doesn’t require a total strip down. But, it would appear that even this briefest of looks isn’t getting done as often as it should.

So, the biggest question is what should be done about this kind of doctor-to-doctor inconsistency? Is it worth doing anything about? It is certainly creating some discomfort for physicians who have to explain and defend their practices to patients they have never met before. Is it an issue for the American Academy of Pediatrics to tackle? Should it be a topic for state chapters or local pediatric societies to address? Or, should it just be kept as a topic for physician-to-physician discussions in group practices?

I will be interested to hear what you all think about venturing into the nether regions.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at pdnews@ frontlinemedcom.com.

I recently received an e-mail from a pediatrician who described the awkward situation in her community in which many of the other pediatricians don’t include a genital exam as part of their complete physicals.

While patients who have grown up in her practice expect a complete exam, new patients or the patients of other physicians for whom she is covering are surprised. And, it is usually not a pleasant surprise. I assume she doesn’t force the issue, but I am sure that the differing expectations cast an uncomfortable cloud over the clinical encounter.

This is an unpleasant experience that I have shared with her on more than several occasions. Again, the usual scenario is a new patient who has come from "away"(as we say here in Maine). They may already be skeptical about whether any of us here in the North Country ever finished high school and harbor the unspoken concern that "Vacation Land" is a place that attracts sexual deviants.

As much as we would like to present ourselves as scientists, physicians are no less immune to ambivalence and discomfort with issues of a sexual nature. None of us likes to have our genitals examined regardless of the sex of the examiner, and, most of us have a lingering discomfort being the examiner. I suspect that in large part this discomfort is the result of our concerns about what the examinee and his or her parents are thinking.

This doctor’s e-mail raises at least two issues. First, it is another example of the value of continuity. The young patient who has had his or her genitals examined by the same physician at multiple visits over the course of years is less likely to feel uncomfortable about the process, and this comfort level may delay the inevitable onset of the modesty years.

The bigger issue is really a collection of questions. Should pediatricians include a genital exam when they do complete physicals? The obvious and politically correct answer is "yes." But, my correspondent’s experience and my own say that it isn’t happening. As an example, I have often seen 9-month-old girls with nearly complete labial fusion who have been examined multiple times by other physicians. We can argue about whether there is anything we should do about labial fusion, but the bottom line is that no one was looking for it. Do you share our observations about this inconsistency?

What does constitute a genital exam in a 7-year-old? And, what is its value? I don’t have the answers, but I will share my thoughts. I suspect that a hands-off visual inspection is enough most of the time. Is there pubic hair? Do you see two testicles? Does the penis appear normal in size? This kind of an examination takes seconds and doesn’t require a total strip down. But, it would appear that even this briefest of looks isn’t getting done as often as it should.

So, the biggest question is what should be done about this kind of doctor-to-doctor inconsistency? Is it worth doing anything about? It is certainly creating some discomfort for physicians who have to explain and defend their practices to patients they have never met before. Is it an issue for the American Academy of Pediatrics to tackle? Should it be a topic for state chapters or local pediatric societies to address? Or, should it just be kept as a topic for physician-to-physician discussions in group practices?

I will be interested to hear what you all think about venturing into the nether regions.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at pdnews@ frontlinemedcom.com.

If you are at your desk or have your laptop or tablet handy, take a look at the screen. No, no, not the glowing pixels. Turn the device off and look at the glass surface. Unless you are someone who carries a bottle of glass cleaner in a holster on your belt, you will see a speckled pattern. Depending on how vigilant you are, what you are looking at is a day, or a week, or in my case, several months’ accumulation of sneezes. I recently learned that each of these droplets of dried snot is called a biofilm. I acquired this addition to my vocabulary by chasing down an article I found in one of our local newspapers. ("Researchers report strep bacteria can last up to several months on objects," Portland (Maine) Press Herald, Dec. 29, 2013).

I found the original article in Infection and Immunology ("Biofilm formation enhances fomite survival of S. pneumoniae and S. pyogenes" 2013 Dec. 26 [doi: 10.1128/IAI.01310-13]), and discovered that it was previously thought that once a fomite dried, the bacteria it contained died in a matter of a few days. However, this assumption was based on microbiologic studies using a plankton-containing broth. Using a different technique, the researchers from Buffalo demonstrated that bacteria can survive in biofilm for months and are virulent enough to infect mice.

This is new information about bacterial survival, but does it warrant inclusion in a lay publication intent on alarming its readers? Even if the bacteria from one sneeze survive only for a couple of days as was once thought, the sneezer is going to continue to replenish his environment with fomites for a week or three. And, by the time he is no longer spewing a spray of fomites, a new cohort of children he has exposed will have taken over his role. So, does it really matter whether bacteria survive for 2 days or 2 months?

There is plenty of evidence that bacteria are crafty survivors that can mutate so quickly that they can fill environmental niches in the blink of an eye. For example, some viruses survive longer on hard smooth surfaces than on soft rough ones. Who would have guessed that? Recently, veterinarians have discovered that some individual bovines are "super shedders" of pathogenic Escherichia coli. This may be the result of a coinfection with parasites. It’s not unreasonable to postulate that certain children are also "super shedders," the modern day equivalents of Typhoid Mary. Should we enter the murky twilight zone of ethics and begin looking for the respiratory syncytial virus (RSV) Jasons in our day cares?

Does all this recent news about germ survival and dispersal mean that we are losing the war? Should we rethink the utility of day cares? Or, should we be steam cleaning them every evening on a daily basis?

On the contrary, this news on bacterial survival is good news. When one considers how many virulent bacteria surround our children, it is encouraging how few of them become seriously ill. Looking back on 40 years of practice, it seems to me that with few exceptions, it wasn’t supervirulent germs that were keeping me busy. It was the variability in host vulnerability that made things interesting. The reason that only a few children in a class became sick with strep was less a result of fomite concentration than the poorly understood child to child differences in immune response. It remains our obligation to be frugal with our use of antibiotics so that when those few unlucky or vulnerable children become ill, we will have an effective arsenal.

Look back at your computer screen. The authors of a recent letter to the editor in the American Journal of Infection Control report that a damp microfiber cloth was effective in removing methicillin-resistant Staphylococcus aureus (MRSA) type A bacteria from iPad screens (Am. J. Infect. Control 2013;41:1136-7). That’s what my grandmother would have suggested.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

If you are at your desk or have your laptop or tablet handy, take a look at the screen. No, no, not the glowing pixels. Turn the device off and look at the glass surface. Unless you are someone who carries a bottle of glass cleaner in a holster on your belt, you will see a speckled pattern. Depending on how vigilant you are, what you are looking at is a day, or a week, or in my case, several months’ accumulation of sneezes. I recently learned that each of these droplets of dried snot is called a biofilm. I acquired this addition to my vocabulary by chasing down an article I found in one of our local newspapers. ("Researchers report strep bacteria can last up to several months on objects," Portland (Maine) Press Herald, Dec. 29, 2013).

I found the original article in Infection and Immunology ("Biofilm formation enhances fomite survival of S. pneumoniae and S. pyogenes" 2013 Dec. 26 [doi: 10.1128/IAI.01310-13]), and discovered that it was previously thought that once a fomite dried, the bacteria it contained died in a matter of a few days. However, this assumption was based on microbiologic studies using a plankton-containing broth. Using a different technique, the researchers from Buffalo demonstrated that bacteria can survive in biofilm for months and are virulent enough to infect mice.

This is new information about bacterial survival, but does it warrant inclusion in a lay publication intent on alarming its readers? Even if the bacteria from one sneeze survive only for a couple of days as was once thought, the sneezer is going to continue to replenish his environment with fomites for a week or three. And, by the time he is no longer spewing a spray of fomites, a new cohort of children he has exposed will have taken over his role. So, does it really matter whether bacteria survive for 2 days or 2 months?

There is plenty of evidence that bacteria are crafty survivors that can mutate so quickly that they can fill environmental niches in the blink of an eye. For example, some viruses survive longer on hard smooth surfaces than on soft rough ones. Who would have guessed that? Recently, veterinarians have discovered that some individual bovines are "super shedders" of pathogenic Escherichia coli. This may be the result of a coinfection with parasites. It’s not unreasonable to postulate that certain children are also "super shedders," the modern day equivalents of Typhoid Mary. Should we enter the murky twilight zone of ethics and begin looking for the respiratory syncytial virus (RSV) Jasons in our day cares?

Does all this recent news about germ survival and dispersal mean that we are losing the war? Should we rethink the utility of day cares? Or, should we be steam cleaning them every evening on a daily basis?

On the contrary, this news on bacterial survival is good news. When one considers how many virulent bacteria surround our children, it is encouraging how few of them become seriously ill. Looking back on 40 years of practice, it seems to me that with few exceptions, it wasn’t supervirulent germs that were keeping me busy. It was the variability in host vulnerability that made things interesting. The reason that only a few children in a class became sick with strep was less a result of fomite concentration than the poorly understood child to child differences in immune response. It remains our obligation to be frugal with our use of antibiotics so that when those few unlucky or vulnerable children become ill, we will have an effective arsenal.

Look back at your computer screen. The authors of a recent letter to the editor in the American Journal of Infection Control report that a damp microfiber cloth was effective in removing methicillin-resistant Staphylococcus aureus (MRSA) type A bacteria from iPad screens (Am. J. Infect. Control 2013;41:1136-7). That’s what my grandmother would have suggested.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

If you are at your desk or have your laptop or tablet handy, take a look at the screen. No, no, not the glowing pixels. Turn the device off and look at the glass surface. Unless you are someone who carries a bottle of glass cleaner in a holster on your belt, you will see a speckled pattern. Depending on how vigilant you are, what you are looking at is a day, or a week, or in my case, several months’ accumulation of sneezes. I recently learned that each of these droplets of dried snot is called a biofilm. I acquired this addition to my vocabulary by chasing down an article I found in one of our local newspapers. ("Researchers report strep bacteria can last up to several months on objects," Portland (Maine) Press Herald, Dec. 29, 2013).

I found the original article in Infection and Immunology ("Biofilm formation enhances fomite survival of S. pneumoniae and S. pyogenes" 2013 Dec. 26 [doi: 10.1128/IAI.01310-13]), and discovered that it was previously thought that once a fomite dried, the bacteria it contained died in a matter of a few days. However, this assumption was based on microbiologic studies using a plankton-containing broth. Using a different technique, the researchers from Buffalo demonstrated that bacteria can survive in biofilm for months and are virulent enough to infect mice.

This is new information about bacterial survival, but does it warrant inclusion in a lay publication intent on alarming its readers? Even if the bacteria from one sneeze survive only for a couple of days as was once thought, the sneezer is going to continue to replenish his environment with fomites for a week or three. And, by the time he is no longer spewing a spray of fomites, a new cohort of children he has exposed will have taken over his role. So, does it really matter whether bacteria survive for 2 days or 2 months?

There is plenty of evidence that bacteria are crafty survivors that can mutate so quickly that they can fill environmental niches in the blink of an eye. For example, some viruses survive longer on hard smooth surfaces than on soft rough ones. Who would have guessed that? Recently, veterinarians have discovered that some individual bovines are "super shedders" of pathogenic Escherichia coli. This may be the result of a coinfection with parasites. It’s not unreasonable to postulate that certain children are also "super shedders," the modern day equivalents of Typhoid Mary. Should we enter the murky twilight zone of ethics and begin looking for the respiratory syncytial virus (RSV) Jasons in our day cares?

Does all this recent news about germ survival and dispersal mean that we are losing the war? Should we rethink the utility of day cares? Or, should we be steam cleaning them every evening on a daily basis?

On the contrary, this news on bacterial survival is good news. When one considers how many virulent bacteria surround our children, it is encouraging how few of them become seriously ill. Looking back on 40 years of practice, it seems to me that with few exceptions, it wasn’t supervirulent germs that were keeping me busy. It was the variability in host vulnerability that made things interesting. The reason that only a few children in a class became sick with strep was less a result of fomite concentration than the poorly understood child to child differences in immune response. It remains our obligation to be frugal with our use of antibiotics so that when those few unlucky or vulnerable children become ill, we will have an effective arsenal.

Look back at your computer screen. The authors of a recent letter to the editor in the American Journal of Infection Control report that a damp microfiber cloth was effective in removing methicillin-resistant Staphylococcus aureus (MRSA) type A bacteria from iPad screens (Am. J. Infect. Control 2013;41:1136-7). That’s what my grandmother would have suggested.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].