Letters from Maine

 

You may not realize it, but as you navigated through this morning’s hospital rounds and your busy office schedule, some of what you did and how you did it was the result of the pioneering work of Boston-based pediatrician T. Berry Brazelton, MD, who died March 13, 2018, at the age of 99.

You probably found the newborn you needed to examine in his mother’s hospital room. The 3-year-old in the croup tent was sharing his room with his father, who was sleeping on a cot at his crib side, and three out of the first four patients you saw in your office had been breastfed. These scenarios would have been unheard of 50 years ago. But Dr. Brazelton’s voice was the most widely heard, yet gentlest and persuasive in support of rooming-in and breastfeeding.

Although I was fortunate to have had dinner with Benjamin Spock’s widow, I never met Dr. Spock himself. However, I did interact on several occasions with the man who inherited his mantle as the most well-recognized pediatrician in America. Dr. T. Berry Brazelton and his fellows played an active role in the pediatric training of those of us who rotated through Boston Children’s Hospital as medical students and house officers.

Watching Dr. Brazelton examine a newborn for the first time was a unique experience and a critical turning point in my training. My fellow house officers and I had been accustomed to picking up infants to assess their tone. However, when Dr. Brazelton picked up a newborn, it was more like a conversation, an interview, and in a sense, it was a meeting of the minds.

It wasn’t that we had been rejecting the notion that a newborn could have a personality. It is just that we hadn’t been taught to look for it or to take it seriously. Dr. Brazelton taught us how to examine the person inside that little body and understand the importance of her temperament. By sharing what we learned from doing a Brazelton-style exam, we hoped to encourage the child’s parents to adopt more realistic expectations, and as a consequence, make parenting less mysterious and stressful.

When I first met Dr. Brazelton, he was in his mid-40s and just beginning on his trajectory toward national prominence. When we were assigned to take care of his hospitalized patients, it was obvious that his patient skills with sick children had taken a back seat to his interest in newborn temperament. He was more than willing to let us make the management decisions. In retrospect, that experience was a warning that I, like many other pediatricians, would face the similar challenge of maintaining my clinical skills in the face of a patient mix that was steadily acquiring a more behavioral and developmental flavor.

It is impossible to quantify the degree to which Dr. Brazelton’s ubiquity contributed to the popularity of a more child-centered parenting style. However, I think it would be unfair to blame him for the unfortunate phenomenon known as “helicopter parenting.”

 

He has been quoted as saying, “I would like to look at what can be done to get parents to relax and not to take [parenthood] too seriously.” (“T. Berry Brazelton, doctor who challenged parents to read babies’ cues, dies,” Washington Post, March 14, 2018). And for the most part with his calm and gentle demeanor, he achieved his goal. Unfortunately, not every parent who tried to follow Dr. Brazelton’s advice about reading their baby’s cues was successful. With his passing, it is up to us as pediatricians to continue comforting those parents who are struggling and echo his reassuring message.

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.” Email him at [email protected].

 

You may not realize it, but as you navigated through this morning’s hospital rounds and your busy office schedule, some of what you did and how you did it was the result of the pioneering work of Boston-based pediatrician T. Berry Brazelton, MD, who died March 13, 2018, at the age of 99.

You probably found the newborn you needed to examine in his mother’s hospital room. The 3-year-old in the croup tent was sharing his room with his father, who was sleeping on a cot at his crib side, and three out of the first four patients you saw in your office had been breastfed. These scenarios would have been unheard of 50 years ago. But Dr. Brazelton’s voice was the most widely heard, yet gentlest and persuasive in support of rooming-in and breastfeeding.

Although I was fortunate to have had dinner with Benjamin Spock’s widow, I never met Dr. Spock himself. However, I did interact on several occasions with the man who inherited his mantle as the most well-recognized pediatrician in America. Dr. T. Berry Brazelton and his fellows played an active role in the pediatric training of those of us who rotated through Boston Children’s Hospital as medical students and house officers.

Watching Dr. Brazelton examine a newborn for the first time was a unique experience and a critical turning point in my training. My fellow house officers and I had been accustomed to picking up infants to assess their tone. However, when Dr. Brazelton picked up a newborn, it was more like a conversation, an interview, and in a sense, it was a meeting of the minds.

It wasn’t that we had been rejecting the notion that a newborn could have a personality. It is just that we hadn’t been taught to look for it or to take it seriously. Dr. Brazelton taught us how to examine the person inside that little body and understand the importance of her temperament. By sharing what we learned from doing a Brazelton-style exam, we hoped to encourage the child’s parents to adopt more realistic expectations, and as a consequence, make parenting less mysterious and stressful.

When I first met Dr. Brazelton, he was in his mid-40s and just beginning on his trajectory toward national prominence. When we were assigned to take care of his hospitalized patients, it was obvious that his patient skills with sick children had taken a back seat to his interest in newborn temperament. He was more than willing to let us make the management decisions. In retrospect, that experience was a warning that I, like many other pediatricians, would face the similar challenge of maintaining my clinical skills in the face of a patient mix that was steadily acquiring a more behavioral and developmental flavor.

It is impossible to quantify the degree to which Dr. Brazelton’s ubiquity contributed to the popularity of a more child-centered parenting style. However, I think it would be unfair to blame him for the unfortunate phenomenon known as “helicopter parenting.”

 

He has been quoted as saying, “I would like to look at what can be done to get parents to relax and not to take [parenthood] too seriously.” (“T. Berry Brazelton, doctor who challenged parents to read babies’ cues, dies,” Washington Post, March 14, 2018). And for the most part with his calm and gentle demeanor, he achieved his goal. Unfortunately, not every parent who tried to follow Dr. Brazelton’s advice about reading their baby’s cues was successful. With his passing, it is up to us as pediatricians to continue comforting those parents who are struggling and echo his reassuring message.

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.” Email him at [email protected].

 

You may not realize it, but as you navigated through this morning’s hospital rounds and your busy office schedule, some of what you did and how you did it was the result of the pioneering work of Boston-based pediatrician T. Berry Brazelton, MD, who died March 13, 2018, at the age of 99.

You probably found the newborn you needed to examine in his mother’s hospital room. The 3-year-old in the croup tent was sharing his room with his father, who was sleeping on a cot at his crib side, and three out of the first four patients you saw in your office had been breastfed. These scenarios would have been unheard of 50 years ago. But Dr. Brazelton’s voice was the most widely heard, yet gentlest and persuasive in support of rooming-in and breastfeeding.

Although I was fortunate to have had dinner with Benjamin Spock’s widow, I never met Dr. Spock himself. However, I did interact on several occasions with the man who inherited his mantle as the most well-recognized pediatrician in America. Dr. T. Berry Brazelton and his fellows played an active role in the pediatric training of those of us who rotated through Boston Children’s Hospital as medical students and house officers.

Watching Dr. Brazelton examine a newborn for the first time was a unique experience and a critical turning point in my training. My fellow house officers and I had been accustomed to picking up infants to assess their tone. However, when Dr. Brazelton picked up a newborn, it was more like a conversation, an interview, and in a sense, it was a meeting of the minds.

It wasn’t that we had been rejecting the notion that a newborn could have a personality. It is just that we hadn’t been taught to look for it or to take it seriously. Dr. Brazelton taught us how to examine the person inside that little body and understand the importance of her temperament. By sharing what we learned from doing a Brazelton-style exam, we hoped to encourage the child’s parents to adopt more realistic expectations, and as a consequence, make parenting less mysterious and stressful.

When I first met Dr. Brazelton, he was in his mid-40s and just beginning on his trajectory toward national prominence. When we were assigned to take care of his hospitalized patients, it was obvious that his patient skills with sick children had taken a back seat to his interest in newborn temperament. He was more than willing to let us make the management decisions. In retrospect, that experience was a warning that I, like many other pediatricians, would face the similar challenge of maintaining my clinical skills in the face of a patient mix that was steadily acquiring a more behavioral and developmental flavor.

It is impossible to quantify the degree to which Dr. Brazelton’s ubiquity contributed to the popularity of a more child-centered parenting style. However, I think it would be unfair to blame him for the unfortunate phenomenon known as “helicopter parenting.”

 

He has been quoted as saying, “I would like to look at what can be done to get parents to relax and not to take [parenthood] too seriously.” (“T. Berry Brazelton, doctor who challenged parents to read babies’ cues, dies,” Washington Post, March 14, 2018). And for the most part with his calm and gentle demeanor, he achieved his goal. Unfortunately, not every parent who tried to follow Dr. Brazelton’s advice about reading their baby’s cues was successful. With his passing, it is up to us as pediatricians to continue comforting those parents who are struggling and echo his reassuring message.

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.” Email him at [email protected].

 

I’ve never been a fan of delayed school start times for high school students. The data just don’t impress me. But mostly I think delayed start times should be just one component of a broad community-wide initiative to address sleep hygiene that includes discussions about bedtimes, after-school schedules, and overuse of electronic devices. And I don’t see those discussions happening.

In most communities, delaying start times for adolescents will mean that younger children will be starting their school days earlier. Buses and drivers are finite and expensive resources that must be shared. Although I have heard it used as an argument against delayed school starts for high schoolers, an earlier start time for grade-school age children is not one of the downsides I include on my list of negatives. In fact, from my perspective, getting youngsters to school early is one of the few advantages of a delayed school start program for high school.

DGLimages/Thinkstock

Unless they have been up watching late night television with their parents, most young children hit the ground running as the sun peeks over the horizon. Keeping an energized youngster entertained and out of trouble until it is time to go to the bus stop can be a challenge. Too often parents resort to television or other electronic devices to bridge this gap between wake up and school start. For some reason, this boundless morning energy of youth isn’t directed toward the mundane tasks of eating breakfast and getting dressed.

I recently heard of an exercise program that harnesses this early-morning energy of youth with positive and not surprising results. Underwritten by the Reebok athletic footwear manufacturer, the BOKS (Build Our Kids’ Success) program began in 2009 when a group of mothers in Massachusetts organized a before-school activity program in their local grade school (“A before-school exercise program may help children thrive,” by Gretchen Reynolds, New York Times, Feb. 14, 2018). They may have been motivated primarily by the need to survive those difficult morning hours, but clearly they weren’t alone in their concerns, and the concept has spread to include 3,000 schools worldwide.

 

Hoping to document the anecdotal observations of the program’s success, researchers from Harvard and the Massachusetts General Hospital surveyed children in 24 schools (“Effects of Before-School Physical Activity on Obesity Prevention and Wellness,” Am J Prev Med. 2018. Feb 12. doi: 10.1016/j.amepre.2018.01.017). Participation in the program was voluntary, and the control group consisted of children whose families chose not to participate. Those children in the before-school activity program 3 mornings per week were more likely to have lower body mass index z scores and “demonstrated improvement in their student engagement scores.” The children who participated only 2 days per week had no significant changes in their body mass index scores. However, they did demonstrate “significant improvements in positive affect and vitality/energy.”

Of course, the study is riddled with caveats. The volunteers may have come from demographics that conferred on them an advantage even before the study began. Scaling the apparent success of the program to other school systems presents obvious problems including funding (even with support from a large corporation), the availability of volunteers, and possible resistance by teachers who might understandably view it as extending their workday. And, of course, it may come down to transportation as the limiting factor. It’s those buses again.

The early-morning energy of youth is a given. The problem is that many children find themselves in home environments in which that energy is squandered or at least misdirected. School can be the environment in which that physical exuberance is allowed to run its natural course. We simply need the will to invest in what needs to be done to make it happen.

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.” Email him at [email protected].

 

I’ve never been a fan of delayed school start times for high school students. The data just don’t impress me. But mostly I think delayed start times should be just one component of a broad community-wide initiative to address sleep hygiene that includes discussions about bedtimes, after-school schedules, and overuse of electronic devices. And I don’t see those discussions happening.

In most communities, delaying start times for adolescents will mean that younger children will be starting their school days earlier. Buses and drivers are finite and expensive resources that must be shared. Although I have heard it used as an argument against delayed school starts for high schoolers, an earlier start time for grade-school age children is not one of the downsides I include on my list of negatives. In fact, from my perspective, getting youngsters to school early is one of the few advantages of a delayed school start program for high school.

DGLimages/Thinkstock

Unless they have been up watching late night television with their parents, most young children hit the ground running as the sun peeks over the horizon. Keeping an energized youngster entertained and out of trouble until it is time to go to the bus stop can be a challenge. Too often parents resort to television or other electronic devices to bridge this gap between wake up and school start. For some reason, this boundless morning energy of youth isn’t directed toward the mundane tasks of eating breakfast and getting dressed.

I recently heard of an exercise program that harnesses this early-morning energy of youth with positive and not surprising results. Underwritten by the Reebok athletic footwear manufacturer, the BOKS (Build Our Kids’ Success) program began in 2009 when a group of mothers in Massachusetts organized a before-school activity program in their local grade school (“A before-school exercise program may help children thrive,” by Gretchen Reynolds, New York Times, Feb. 14, 2018). They may have been motivated primarily by the need to survive those difficult morning hours, but clearly they weren’t alone in their concerns, and the concept has spread to include 3,000 schools worldwide.

 

Hoping to document the anecdotal observations of the program’s success, researchers from Harvard and the Massachusetts General Hospital surveyed children in 24 schools (“Effects of Before-School Physical Activity on Obesity Prevention and Wellness,” Am J Prev Med. 2018. Feb 12. doi: 10.1016/j.amepre.2018.01.017). Participation in the program was voluntary, and the control group consisted of children whose families chose not to participate. Those children in the before-school activity program 3 mornings per week were more likely to have lower body mass index z scores and “demonstrated improvement in their student engagement scores.” The children who participated only 2 days per week had no significant changes in their body mass index scores. However, they did demonstrate “significant improvements in positive affect and vitality/energy.”

Of course, the study is riddled with caveats. The volunteers may have come from demographics that conferred on them an advantage even before the study began. Scaling the apparent success of the program to other school systems presents obvious problems including funding (even with support from a large corporation), the availability of volunteers, and possible resistance by teachers who might understandably view it as extending their workday. And, of course, it may come down to transportation as the limiting factor. It’s those buses again.

The early-morning energy of youth is a given. The problem is that many children find themselves in home environments in which that energy is squandered or at least misdirected. School can be the environment in which that physical exuberance is allowed to run its natural course. We simply need the will to invest in what needs to be done to make it happen.

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.” Email him at [email protected].

 

I’ve never been a fan of delayed school start times for high school students. The data just don’t impress me. But mostly I think delayed start times should be just one component of a broad community-wide initiative to address sleep hygiene that includes discussions about bedtimes, after-school schedules, and overuse of electronic devices. And I don’t see those discussions happening.

In most communities, delaying start times for adolescents will mean that younger children will be starting their school days earlier. Buses and drivers are finite and expensive resources that must be shared. Although I have heard it used as an argument against delayed school starts for high schoolers, an earlier start time for grade-school age children is not one of the downsides I include on my list of negatives. In fact, from my perspective, getting youngsters to school early is one of the few advantages of a delayed school start program for high school.

DGLimages/Thinkstock

Unless they have been up watching late night television with their parents, most young children hit the ground running as the sun peeks over the horizon. Keeping an energized youngster entertained and out of trouble until it is time to go to the bus stop can be a challenge. Too often parents resort to television or other electronic devices to bridge this gap between wake up and school start. For some reason, this boundless morning energy of youth isn’t directed toward the mundane tasks of eating breakfast and getting dressed.

I recently heard of an exercise program that harnesses this early-morning energy of youth with positive and not surprising results. Underwritten by the Reebok athletic footwear manufacturer, the BOKS (Build Our Kids’ Success) program began in 2009 when a group of mothers in Massachusetts organized a before-school activity program in their local grade school (“A before-school exercise program may help children thrive,” by Gretchen Reynolds, New York Times, Feb. 14, 2018). They may have been motivated primarily by the need to survive those difficult morning hours, but clearly they weren’t alone in their concerns, and the concept has spread to include 3,000 schools worldwide.

 

Hoping to document the anecdotal observations of the program’s success, researchers from Harvard and the Massachusetts General Hospital surveyed children in 24 schools (“Effects of Before-School Physical Activity on Obesity Prevention and Wellness,” Am J Prev Med. 2018. Feb 12. doi: 10.1016/j.amepre.2018.01.017). Participation in the program was voluntary, and the control group consisted of children whose families chose not to participate. Those children in the before-school activity program 3 mornings per week were more likely to have lower body mass index z scores and “demonstrated improvement in their student engagement scores.” The children who participated only 2 days per week had no significant changes in their body mass index scores. However, they did demonstrate “significant improvements in positive affect and vitality/energy.”

Of course, the study is riddled with caveats. The volunteers may have come from demographics that conferred on them an advantage even before the study began. Scaling the apparent success of the program to other school systems presents obvious problems including funding (even with support from a large corporation), the availability of volunteers, and possible resistance by teachers who might understandably view it as extending their workday. And, of course, it may come down to transportation as the limiting factor. It’s those buses again.

The early-morning energy of youth is a given. The problem is that many children find themselves in home environments in which that energy is squandered or at least misdirected. School can be the environment in which that physical exuberance is allowed to run its natural course. We simply need the will to invest in what needs to be done to make it happen.

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.” Email him at [email protected].

 

I grew up in a diversity-free zone. The bubble surrounding Pleasantville, New York, in the 1950s and 1960s didn’t include people of color. We were all middle-class, some upper, some lower, some blue collar, some white collar – but, all of us comfortably in the middle. The children with disabilities must have been hidden in their homes or housed in institutions. They certainly weren’t our classmates. We were spread across the broad Judeo-Christian spectrum. Who knew there were other religions?

Of course, when I left for college I entered another even less inclusive bubble that didn’t admit women.

diego_cervo/Thinkstock

But diversity happens, and my grandchildren here in Maine have classmates of color (of course, not as many as in other less remote parts of the country). They think nothing of sharing their classrooms with children with disabilities. They don’t think it is weird that some of their classmates have two mommies. They have close friends whose uncles are openly gay. Although the economic spectrum here in Brunswick is only slightly broader than where I grew up, my grandchildren can travel just a few miles to see what poverty looks like.

For many years, the process that brought about this dramatic change was a fortuitous conglomeration of brush wars fought by courageous individuals and minority groups. However, in the last decade or two, the struggle for inclusion has broadened under the banner of diversity, a term once primarily used to describe evolving ecologic populations. In light of this expanding definition, it is not surprising that the American Academy of Pediatrics has begun to consider its role in promoting diversity. As reported in AAP News (Anne Hegland, March 2018) the American Academy of Pediatrics board of directors recently discussed a plan for implementing at “all levels of the Academy” the suggestions of its Task Force on Diversity and Inclusion.

 

I am confident that most of the changes that come in the wake of the academy’s initiative will be positive. However, this is a time in the life of this country when one must accept that “diversity,” “inclusion,” and their close cousin “multiculturalism” are not universally viewed as goals worthy of pursuit. The words have taken on a buzz that at times I find annoying, and some folks may feel they have heard more than enough about diversity and multiculturalism. Even though I think the terms have been overused, I don’t share their view because I believe we still have a long way to go before we are truly inclusive.

The academy is in the enviable positive of having a membership that agrees in general terms where its priorities should be – the health and welfare of children. It can afford to invest some of its energies in being more inclusive. However, the United States currently is struggling to rediscover a set of priorities that its citizens can agree on. We have politicians who would rather win a battle over their adversaries than address the obvious needs of the country. And, we have journalists who prefer to feast on these battles rather than search for evidence of cooperation. This is not a time to sharpen our focus on how different we are from one another. It is time to raise another flag along side the “diversity” banner. It should read “commonality,” and remind us that while we are celebrating our differences, we must work harder to uncover the core values that we share.

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.” Email him at [email protected].

 

I grew up in a diversity-free zone. The bubble surrounding Pleasantville, New York, in the 1950s and 1960s didn’t include people of color. We were all middle-class, some upper, some lower, some blue collar, some white collar – but, all of us comfortably in the middle. The children with disabilities must have been hidden in their homes or housed in institutions. They certainly weren’t our classmates. We were spread across the broad Judeo-Christian spectrum. Who knew there were other religions?

Of course, when I left for college I entered another even less inclusive bubble that didn’t admit women.

diego_cervo/Thinkstock

But diversity happens, and my grandchildren here in Maine have classmates of color (of course, not as many as in other less remote parts of the country). They think nothing of sharing their classrooms with children with disabilities. They don’t think it is weird that some of their classmates have two mommies. They have close friends whose uncles are openly gay. Although the economic spectrum here in Brunswick is only slightly broader than where I grew up, my grandchildren can travel just a few miles to see what poverty looks like.

For many years, the process that brought about this dramatic change was a fortuitous conglomeration of brush wars fought by courageous individuals and minority groups. However, in the last decade or two, the struggle for inclusion has broadened under the banner of diversity, a term once primarily used to describe evolving ecologic populations. In light of this expanding definition, it is not surprising that the American Academy of Pediatrics has begun to consider its role in promoting diversity. As reported in AAP News (Anne Hegland, March 2018) the American Academy of Pediatrics board of directors recently discussed a plan for implementing at “all levels of the Academy” the suggestions of its Task Force on Diversity and Inclusion.

 

I am confident that most of the changes that come in the wake of the academy’s initiative will be positive. However, this is a time in the life of this country when one must accept that “diversity,” “inclusion,” and their close cousin “multiculturalism” are not universally viewed as goals worthy of pursuit. The words have taken on a buzz that at times I find annoying, and some folks may feel they have heard more than enough about diversity and multiculturalism. Even though I think the terms have been overused, I don’t share their view because I believe we still have a long way to go before we are truly inclusive.

The academy is in the enviable positive of having a membership that agrees in general terms where its priorities should be – the health and welfare of children. It can afford to invest some of its energies in being more inclusive. However, the United States currently is struggling to rediscover a set of priorities that its citizens can agree on. We have politicians who would rather win a battle over their adversaries than address the obvious needs of the country. And, we have journalists who prefer to feast on these battles rather than search for evidence of cooperation. This is not a time to sharpen our focus on how different we are from one another. It is time to raise another flag along side the “diversity” banner. It should read “commonality,” and remind us that while we are celebrating our differences, we must work harder to uncover the core values that we share.

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.” Email him at [email protected].

 

I grew up in a diversity-free zone. The bubble surrounding Pleasantville, New York, in the 1950s and 1960s didn’t include people of color. We were all middle-class, some upper, some lower, some blue collar, some white collar – but, all of us comfortably in the middle. The children with disabilities must have been hidden in their homes or housed in institutions. They certainly weren’t our classmates. We were spread across the broad Judeo-Christian spectrum. Who knew there were other religions?

Of course, when I left for college I entered another even less inclusive bubble that didn’t admit women.

diego_cervo/Thinkstock

But diversity happens, and my grandchildren here in Maine have classmates of color (of course, not as many as in other less remote parts of the country). They think nothing of sharing their classrooms with children with disabilities. They don’t think it is weird that some of their classmates have two mommies. They have close friends whose uncles are openly gay. Although the economic spectrum here in Brunswick is only slightly broader than where I grew up, my grandchildren can travel just a few miles to see what poverty looks like.

For many years, the process that brought about this dramatic change was a fortuitous conglomeration of brush wars fought by courageous individuals and minority groups. However, in the last decade or two, the struggle for inclusion has broadened under the banner of diversity, a term once primarily used to describe evolving ecologic populations. In light of this expanding definition, it is not surprising that the American Academy of Pediatrics has begun to consider its role in promoting diversity. As reported in AAP News (Anne Hegland, March 2018) the American Academy of Pediatrics board of directors recently discussed a plan for implementing at “all levels of the Academy” the suggestions of its Task Force on Diversity and Inclusion.

 

I am confident that most of the changes that come in the wake of the academy’s initiative will be positive. However, this is a time in the life of this country when one must accept that “diversity,” “inclusion,” and their close cousin “multiculturalism” are not universally viewed as goals worthy of pursuit. The words have taken on a buzz that at times I find annoying, and some folks may feel they have heard more than enough about diversity and multiculturalism. Even though I think the terms have been overused, I don’t share their view because I believe we still have a long way to go before we are truly inclusive.

The academy is in the enviable positive of having a membership that agrees in general terms where its priorities should be – the health and welfare of children. It can afford to invest some of its energies in being more inclusive. However, the United States currently is struggling to rediscover a set of priorities that its citizens can agree on. We have politicians who would rather win a battle over their adversaries than address the obvious needs of the country. And, we have journalists who prefer to feast on these battles rather than search for evidence of cooperation. This is not a time to sharpen our focus on how different we are from one another. It is time to raise another flag along side the “diversity” banner. It should read “commonality,” and remind us that while we are celebrating our differences, we must work harder to uncover the core values that we share.

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.” Email him at [email protected].

 

Even if you have never experienced a symptom of burnout, you probably have at least one colleague who has. In the last decade, collateral damage from physician burnout has earned it a place on the agenda of the American Academy of Pediatrics and most other physician organizations.

When one steps back and takes a longer view, burnout is simply a poor fit between physicians and their roles. An increasing number of physicians are finding themselves in jobs in which – for a variety of reasons – they feel uncomfortable. Eventually, the discomfort resulting from that poor fit becomes so unbearable the only solution is to change jobs or retire.

monkeybusinessimages/Thinkstock

Is the increase in burnout an indication that the role of the physician has changed? Or is it because people entering the profession are less adaptable than their predecessors to the demands of the job? That older physicians and physicians in training are experiencing burnout suggests that a change in the demands of the job is at least partly responsible.

However, an article in Pediatrics entitled “Seeking professional resilience” addresses burnout from the perspective that physician vulnerability is a major contributor to the problem (Pediatrics. 2018, Feb 1. doi: 10.1542/peds.2017-2388). The author, Abby R. Rosenberg, MD, suggests that one solution to burnout is helping physicians learn how “to maintain physical and emotional well-being in the face of adversity,” that is, “resilience.”

It turns out that the recent buzz surrounding “resilience” has drawn a throng of theorists. I guess if we can have chaos theory, we can have resilience theories. Dr. Rosenberg sorts these theories into three categories based on whether they consider resilience an intrinsic trait, a process of adaptation, or an outcome. She offers an alternative description in which resilience is conceived as “a process of harnessing the resources we need to sustain well-being.” Dr. Rosenberg’s suggestions of how this harnessing process can be achieved are certainly worth reading, but I fear that most physicians threatened with burnout won’t have the time or the composure to follow her recommendations. Fifty years of watching physicians both thrive and flame out has convinced me that in most cases, resilience is an intrinsic trait gifted to the recipient at birth.

I am sure there are older physicians who believe that burnout is just another case of “they-don’t-make-’em-like-they-used-to” and would claim that young physicians just don’t have the same grit that we had a generation ago. I guess it is possible that the shift away from the owner/operator model toward one in which a physician has become a cog in the wheel of a large corporation has selected for physicians who are less resilient by nature. But I suspect that the number of resilient physicians is unchanged over the last hundred years. It is more likely that even those blessed with a resilient nature enter their training challenged by a burden of debt significantly greater than my peers and I faced 50 years ago.

The problem isn’t the resiliency deficit. Burnout is the result of a job that has evolved into one with challenges that even the more resilient physicians struggle to tolerate. Under a litigious cloud, hunched over a computer for half the day, the modern physician must struggle to find relevance in a situation in which he has relinquished control to a system that may not share his values.

Refining the selection process to find even more resilient candidates for medical school might lower the burnout rate by a point or two. However, the real answer requires a major overhaul of medical delivery system so that providers can once again feel that every hour they invest is meaningful. The privilege to practice medicine always has required sacrifices on the part of the physician. However, without a sense of purpose, these sacrifices can become intolerable.

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.” Email him at [email protected].

 

Even if you have never experienced a symptom of burnout, you probably have at least one colleague who has. In the last decade, collateral damage from physician burnout has earned it a place on the agenda of the American Academy of Pediatrics and most other physician organizations.

When one steps back and takes a longer view, burnout is simply a poor fit between physicians and their roles. An increasing number of physicians are finding themselves in jobs in which – for a variety of reasons – they feel uncomfortable. Eventually, the discomfort resulting from that poor fit becomes so unbearable the only solution is to change jobs or retire.

monkeybusinessimages/Thinkstock

Is the increase in burnout an indication that the role of the physician has changed? Or is it because people entering the profession are less adaptable than their predecessors to the demands of the job? That older physicians and physicians in training are experiencing burnout suggests that a change in the demands of the job is at least partly responsible.

However, an article in Pediatrics entitled “Seeking professional resilience” addresses burnout from the perspective that physician vulnerability is a major contributor to the problem (Pediatrics. 2018, Feb 1. doi: 10.1542/peds.2017-2388). The author, Abby R. Rosenberg, MD, suggests that one solution to burnout is helping physicians learn how “to maintain physical and emotional well-being in the face of adversity,” that is, “resilience.”

It turns out that the recent buzz surrounding “resilience” has drawn a throng of theorists. I guess if we can have chaos theory, we can have resilience theories. Dr. Rosenberg sorts these theories into three categories based on whether they consider resilience an intrinsic trait, a process of adaptation, or an outcome. She offers an alternative description in which resilience is conceived as “a process of harnessing the resources we need to sustain well-being.” Dr. Rosenberg’s suggestions of how this harnessing process can be achieved are certainly worth reading, but I fear that most physicians threatened with burnout won’t have the time or the composure to follow her recommendations. Fifty years of watching physicians both thrive and flame out has convinced me that in most cases, resilience is an intrinsic trait gifted to the recipient at birth.

I am sure there are older physicians who believe that burnout is just another case of “they-don’t-make-’em-like-they-used-to” and would claim that young physicians just don’t have the same grit that we had a generation ago. I guess it is possible that the shift away from the owner/operator model toward one in which a physician has become a cog in the wheel of a large corporation has selected for physicians who are less resilient by nature. But I suspect that the number of resilient physicians is unchanged over the last hundred years. It is more likely that even those blessed with a resilient nature enter their training challenged by a burden of debt significantly greater than my peers and I faced 50 years ago.

The problem isn’t the resiliency deficit. Burnout is the result of a job that has evolved into one with challenges that even the more resilient physicians struggle to tolerate. Under a litigious cloud, hunched over a computer for half the day, the modern physician must struggle to find relevance in a situation in which he has relinquished control to a system that may not share his values.

Refining the selection process to find even more resilient candidates for medical school might lower the burnout rate by a point or two. However, the real answer requires a major overhaul of medical delivery system so that providers can once again feel that every hour they invest is meaningful. The privilege to practice medicine always has required sacrifices on the part of the physician. However, without a sense of purpose, these sacrifices can become intolerable.

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.” Email him at [email protected].

 

Even if you have never experienced a symptom of burnout, you probably have at least one colleague who has. In the last decade, collateral damage from physician burnout has earned it a place on the agenda of the American Academy of Pediatrics and most other physician organizations.

When one steps back and takes a longer view, burnout is simply a poor fit between physicians and their roles. An increasing number of physicians are finding themselves in jobs in which – for a variety of reasons – they feel uncomfortable. Eventually, the discomfort resulting from that poor fit becomes so unbearable the only solution is to change jobs or retire.

monkeybusinessimages/Thinkstock

Is the increase in burnout an indication that the role of the physician has changed? Or is it because people entering the profession are less adaptable than their predecessors to the demands of the job? That older physicians and physicians in training are experiencing burnout suggests that a change in the demands of the job is at least partly responsible.

However, an article in Pediatrics entitled “Seeking professional resilience” addresses burnout from the perspective that physician vulnerability is a major contributor to the problem (Pediatrics. 2018, Feb 1. doi: 10.1542/peds.2017-2388). The author, Abby R. Rosenberg, MD, suggests that one solution to burnout is helping physicians learn how “to maintain physical and emotional well-being in the face of adversity,” that is, “resilience.”

It turns out that the recent buzz surrounding “resilience” has drawn a throng of theorists. I guess if we can have chaos theory, we can have resilience theories. Dr. Rosenberg sorts these theories into three categories based on whether they consider resilience an intrinsic trait, a process of adaptation, or an outcome. She offers an alternative description in which resilience is conceived as “a process of harnessing the resources we need to sustain well-being.” Dr. Rosenberg’s suggestions of how this harnessing process can be achieved are certainly worth reading, but I fear that most physicians threatened with burnout won’t have the time or the composure to follow her recommendations. Fifty years of watching physicians both thrive and flame out has convinced me that in most cases, resilience is an intrinsic trait gifted to the recipient at birth.

I am sure there are older physicians who believe that burnout is just another case of “they-don’t-make-’em-like-they-used-to” and would claim that young physicians just don’t have the same grit that we had a generation ago. I guess it is possible that the shift away from the owner/operator model toward one in which a physician has become a cog in the wheel of a large corporation has selected for physicians who are less resilient by nature. But I suspect that the number of resilient physicians is unchanged over the last hundred years. It is more likely that even those blessed with a resilient nature enter their training challenged by a burden of debt significantly greater than my peers and I faced 50 years ago.

The problem isn’t the resiliency deficit. Burnout is the result of a job that has evolved into one with challenges that even the more resilient physicians struggle to tolerate. Under a litigious cloud, hunched over a computer for half the day, the modern physician must struggle to find relevance in a situation in which he has relinquished control to a system that may not share his values.

Refining the selection process to find even more resilient candidates for medical school might lower the burnout rate by a point or two. However, the real answer requires a major overhaul of medical delivery system so that providers can once again feel that every hour they invest is meaningful. The privilege to practice medicine always has required sacrifices on the part of the physician. However, without a sense of purpose, these sacrifices can become intolerable.

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.” Email him at [email protected].

 

By the time you reach age 55, 18% of your pediatrician colleagues – or you yourself – will have been sued for malpractice. As many as 64% of your brother and sister obstetrician-gynecologists will have suffered the same fate. These numbers come from a pool of recent data released by the American Medical Association that suggest that nearly half of physicians in this country will be sued for malpractice by age 55 years.

tomloel/ThinkStock

A related release by the AMA details the outcomes and financial costs of malpractice suits between 2006 and 2015 (“Medical professional liability insurance indemnity payments, expenses, and claim disposition, 2006-2015,” by Jose R. Guardado, PhD, AMA Policy Research Perspectives, 2018). In a press release accompanying the publication of these two studies AMA President David O. Barbe, MD, MHA, observes, “Even though the vast majority of claims are dropped, dismissed, or withdrawn, the heavy cost associated with a litigious climate takes a significant financial toll on our health care system when the nation is working to reduce unnecessary health care costs.”

I have read the AMA’s press release and the two studies several times and didn’t see a single reference to the emotional toll taken on the health care providers who have been sued. Of course, although it is easy to imagine that the human cost of a malpractice suit is probably high, it is not one of those figures that the number crunchers can find in their data sets and spreadsheets.

As someone who has endured a malpractice suit that went to trial, I can bear personal witness to the emotional challenges that come with litigation. Although a case that goes to trial is unusual (7%), most cases like ours are won by defendants (87.5%). That number was of little or no reassurance to me and my codefendants. Every waking hour during the 7 years that it took our case to play out was darkened by the threat to my professional career. Every trip to the mailbox was an exercise in courage. Would there be another piece of voluminous communication to remind me of the terrible reality?

 

Thanks to my wife and a lawyer who was always concerned about how I was doing emotionally, my story had a happy ending. I survived with my solo practice and my marriage intact. But I know that others have not been as lucky. Chemical dependency, divorce, poor productivity, and early retirement are just part of the underreported collateral damage that can come in the wake of a malpractice case, even one that is resolved with a relatively small financial cost.

Beyond the emotional cost, there is the staggering expense of defensive medicine. It has been going on for so long that many physicians practicing today don’t realize they are practicing defensive medicine because that’s the way they have been taught by several generations of gun-shy mentors.

And, of course, the risk-averse mentality is one of the drivers of the tsunami of computerization that threatens to drown our health care delivery system. The fallacious legal argument that if it wasn’t documented, it didn’t happen, has resulted in a glut of computer-enhanced “documentation” that even the most casual observer realizes isn’t worth the electrons it takes to light up the pixels on a computer screen.

Even if we ignore their incalculable emotional costs, malpractice suits and the litigious climate in which we practice are eating away at our health care delivery system. I certainly don’t have the answers to rein in the costs. I only can recommend that you practice the best medicine you know how, and do it in a manner that demonstrates you care about the patient. And hope you have good lawyer who cares about you more than his fee.

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.” Email him at [email protected].

 

By the time you reach age 55, 18% of your pediatrician colleagues – or you yourself – will have been sued for malpractice. As many as 64% of your brother and sister obstetrician-gynecologists will have suffered the same fate. These numbers come from a pool of recent data released by the American Medical Association that suggest that nearly half of physicians in this country will be sued for malpractice by age 55 years.

tomloel/ThinkStock

A related release by the AMA details the outcomes and financial costs of malpractice suits between 2006 and 2015 (“Medical professional liability insurance indemnity payments, expenses, and claim disposition, 2006-2015,” by Jose R. Guardado, PhD, AMA Policy Research Perspectives, 2018). In a press release accompanying the publication of these two studies AMA President David O. Barbe, MD, MHA, observes, “Even though the vast majority of claims are dropped, dismissed, or withdrawn, the heavy cost associated with a litigious climate takes a significant financial toll on our health care system when the nation is working to reduce unnecessary health care costs.”

I have read the AMA’s press release and the two studies several times and didn’t see a single reference to the emotional toll taken on the health care providers who have been sued. Of course, although it is easy to imagine that the human cost of a malpractice suit is probably high, it is not one of those figures that the number crunchers can find in their data sets and spreadsheets.

As someone who has endured a malpractice suit that went to trial, I can bear personal witness to the emotional challenges that come with litigation. Although a case that goes to trial is unusual (7%), most cases like ours are won by defendants (87.5%). That number was of little or no reassurance to me and my codefendants. Every waking hour during the 7 years that it took our case to play out was darkened by the threat to my professional career. Every trip to the mailbox was an exercise in courage. Would there be another piece of voluminous communication to remind me of the terrible reality?

 

Thanks to my wife and a lawyer who was always concerned about how I was doing emotionally, my story had a happy ending. I survived with my solo practice and my marriage intact. But I know that others have not been as lucky. Chemical dependency, divorce, poor productivity, and early retirement are just part of the underreported collateral damage that can come in the wake of a malpractice case, even one that is resolved with a relatively small financial cost.

Beyond the emotional cost, there is the staggering expense of defensive medicine. It has been going on for so long that many physicians practicing today don’t realize they are practicing defensive medicine because that’s the way they have been taught by several generations of gun-shy mentors.

And, of course, the risk-averse mentality is one of the drivers of the tsunami of computerization that threatens to drown our health care delivery system. The fallacious legal argument that if it wasn’t documented, it didn’t happen, has resulted in a glut of computer-enhanced “documentation” that even the most casual observer realizes isn’t worth the electrons it takes to light up the pixels on a computer screen.

Even if we ignore their incalculable emotional costs, malpractice suits and the litigious climate in which we practice are eating away at our health care delivery system. I certainly don’t have the answers to rein in the costs. I only can recommend that you practice the best medicine you know how, and do it in a manner that demonstrates you care about the patient. And hope you have good lawyer who cares about you more than his fee.

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.” Email him at [email protected].

 

By the time you reach age 55, 18% of your pediatrician colleagues – or you yourself – will have been sued for malpractice. As many as 64% of your brother and sister obstetrician-gynecologists will have suffered the same fate. These numbers come from a pool of recent data released by the American Medical Association that suggest that nearly half of physicians in this country will be sued for malpractice by age 55 years.

tomloel/ThinkStock

A related release by the AMA details the outcomes and financial costs of malpractice suits between 2006 and 2015 (“Medical professional liability insurance indemnity payments, expenses, and claim disposition, 2006-2015,” by Jose R. Guardado, PhD, AMA Policy Research Perspectives, 2018). In a press release accompanying the publication of these two studies AMA President David O. Barbe, MD, MHA, observes, “Even though the vast majority of claims are dropped, dismissed, or withdrawn, the heavy cost associated with a litigious climate takes a significant financial toll on our health care system when the nation is working to reduce unnecessary health care costs.”

I have read the AMA’s press release and the two studies several times and didn’t see a single reference to the emotional toll taken on the health care providers who have been sued. Of course, although it is easy to imagine that the human cost of a malpractice suit is probably high, it is not one of those figures that the number crunchers can find in their data sets and spreadsheets.

As someone who has endured a malpractice suit that went to trial, I can bear personal witness to the emotional challenges that come with litigation. Although a case that goes to trial is unusual (7%), most cases like ours are won by defendants (87.5%). That number was of little or no reassurance to me and my codefendants. Every waking hour during the 7 years that it took our case to play out was darkened by the threat to my professional career. Every trip to the mailbox was an exercise in courage. Would there be another piece of voluminous communication to remind me of the terrible reality?

 

Thanks to my wife and a lawyer who was always concerned about how I was doing emotionally, my story had a happy ending. I survived with my solo practice and my marriage intact. But I know that others have not been as lucky. Chemical dependency, divorce, poor productivity, and early retirement are just part of the underreported collateral damage that can come in the wake of a malpractice case, even one that is resolved with a relatively small financial cost.

Beyond the emotional cost, there is the staggering expense of defensive medicine. It has been going on for so long that many physicians practicing today don’t realize they are practicing defensive medicine because that’s the way they have been taught by several generations of gun-shy mentors.

And, of course, the risk-averse mentality is one of the drivers of the tsunami of computerization that threatens to drown our health care delivery system. The fallacious legal argument that if it wasn’t documented, it didn’t happen, has resulted in a glut of computer-enhanced “documentation” that even the most casual observer realizes isn’t worth the electrons it takes to light up the pixels on a computer screen.

Even if we ignore their incalculable emotional costs, malpractice suits and the litigious climate in which we practice are eating away at our health care delivery system. I certainly don’t have the answers to rein in the costs. I only can recommend that you practice the best medicine you know how, and do it in a manner that demonstrates you care about the patient. And hope you have good lawyer who cares about you more than his fee.

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.” Email him at [email protected].

 

Our first daughter was born during my last year in medical school, and our second was born as I was finishing my second year in residency. Seeing those two little darlings grow and develop was a critical supplement to my pediatric training. And, watching my wife initially struggle and then succeed with breastfeeding provided a very personal experience and education about lactation that my interactions in the hospital and outpatient clinics didn’t offer.

We considered ourselves lucky because my wife wasn’t facing the additional challenge of returning to an out-of-the-home job. However, our good fortune did not confer immunity against the anxiety, insecurity, discomfort, and sleep deprivation–induced frustrations of breastfeeding. Watching my wife navigate the choppy waters of lactation certainly influenced my approach to counseling new mothers over my subsequent 4 decades of practice. I think I was a more sympathetic and realistic adviser based on my first-hand observations.

©Lev Olkha/iStockphoto.com

A recent article in the AAP News addresses this relationship between physicians’ personal experiences with breastfeeding and their clinical interactions with the mothers in their practices (“Facing barriers to breastfeeding may affect physicians’ advocacy for patients,” February 2018). The authors refer to a study in the Journal of Human Lactation reporting that in the group of 927 pediatric trainees who were surveyed, of which 421 had children and 346 breastfed their children, “1 in 4 did not meet their breastfeeding duration goal, and 1 in 3 did not meet their goal for extended breastfeeding,” which was 6 months (J Hum Lact. 2015 May;31[2]:240-8). Twenty-five percent either did not have access to or were not aware of a private room where they could express milk or breastfeed. The resulting failure left the trainees feeling frustrated, depressed, and devastated. More than 90% of the respondents felt that their experiences affected their interactions with mothers in their practices.

In a different survey of American Academy of Pediatrics fellows, more of the 832 pediatricians responding reported having had a personal experience with breastfeeding in 2014 than of the 620 responding in 1995 (68% vs. 42%). However, it is interesting that fewer of the respondents in 2014 felt that any mother can succeed at breastfeeding (predicted value = 70% in 1995, PV = 56% in 2014; P less than .05), and fewer in 2014 believed that the advantages of breastfeeding outweighed the difficulties than among those surveyed in 1995 (PV = 70% in 1995, PV = 50% in 2014; P less than .05) (Pediatrics. 2017 Oct;140[4]. pii: e20171229). These results suggest that, as more pediatricians gained personal experience with breastfeeding, more may have realized that the American Academy of Pediatrics recommendations for breastfeeding are unrealistic and may contribute to the negative experiences of some women, including pediatric trainees.

An implied assumption in the AAP News article is that a pediatrician who has had a negative breastfeeding experience is less likely to be a strong advocate for breastfeeding. I would argue that a pediatrician who has witnessed or personally experienced difficulties is more likely to be a sympathetic and realistic advocate of breastfeeding.

Of course, my argument begs the question of exactly for what and for whom we are advocating. The quick reflex answer might be that, of course we are advocating for children because we have data supporting the benefits for them of exclusive breastfeeding for the first 6 months and extended breastfeeding for 1 year. However, many of us who have practiced pediatrics for more than a couple of decades have observed ample anecdotal evidence that overzealous advocacy for the current breastfeeding guidelines can result in casualties among women whose “failure” has left them depressed, frustrated, and less confident in their ability to mother.

We must walk that fine line between actively advocating for lactation-friendly hospitals and work environments and supporting mothers who, due to circumstances beyond their control, can’t meet the expectations we have created for them.

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.”

 

Our first daughter was born during my last year in medical school, and our second was born as I was finishing my second year in residency. Seeing those two little darlings grow and develop was a critical supplement to my pediatric training. And, watching my wife initially struggle and then succeed with breastfeeding provided a very personal experience and education about lactation that my interactions in the hospital and outpatient clinics didn’t offer.

We considered ourselves lucky because my wife wasn’t facing the additional challenge of returning to an out-of-the-home job. However, our good fortune did not confer immunity against the anxiety, insecurity, discomfort, and sleep deprivation–induced frustrations of breastfeeding. Watching my wife navigate the choppy waters of lactation certainly influenced my approach to counseling new mothers over my subsequent 4 decades of practice. I think I was a more sympathetic and realistic adviser based on my first-hand observations.

©Lev Olkha/iStockphoto.com

A recent article in the AAP News addresses this relationship between physicians’ personal experiences with breastfeeding and their clinical interactions with the mothers in their practices (“Facing barriers to breastfeeding may affect physicians’ advocacy for patients,” February 2018). The authors refer to a study in the Journal of Human Lactation reporting that in the group of 927 pediatric trainees who were surveyed, of which 421 had children and 346 breastfed their children, “1 in 4 did not meet their breastfeeding duration goal, and 1 in 3 did not meet their goal for extended breastfeeding,” which was 6 months (J Hum Lact. 2015 May;31[2]:240-8). Twenty-five percent either did not have access to or were not aware of a private room where they could express milk or breastfeed. The resulting failure left the trainees feeling frustrated, depressed, and devastated. More than 90% of the respondents felt that their experiences affected their interactions with mothers in their practices.

In a different survey of American Academy of Pediatrics fellows, more of the 832 pediatricians responding reported having had a personal experience with breastfeeding in 2014 than of the 620 responding in 1995 (68% vs. 42%). However, it is interesting that fewer of the respondents in 2014 felt that any mother can succeed at breastfeeding (predicted value = 70% in 1995, PV = 56% in 2014; P less than .05), and fewer in 2014 believed that the advantages of breastfeeding outweighed the difficulties than among those surveyed in 1995 (PV = 70% in 1995, PV = 50% in 2014; P less than .05) (Pediatrics. 2017 Oct;140[4]. pii: e20171229). These results suggest that, as more pediatricians gained personal experience with breastfeeding, more may have realized that the American Academy of Pediatrics recommendations for breastfeeding are unrealistic and may contribute to the negative experiences of some women, including pediatric trainees.

An implied assumption in the AAP News article is that a pediatrician who has had a negative breastfeeding experience is less likely to be a strong advocate for breastfeeding. I would argue that a pediatrician who has witnessed or personally experienced difficulties is more likely to be a sympathetic and realistic advocate of breastfeeding.

Of course, my argument begs the question of exactly for what and for whom we are advocating. The quick reflex answer might be that, of course we are advocating for children because we have data supporting the benefits for them of exclusive breastfeeding for the first 6 months and extended breastfeeding for 1 year. However, many of us who have practiced pediatrics for more than a couple of decades have observed ample anecdotal evidence that overzealous advocacy for the current breastfeeding guidelines can result in casualties among women whose “failure” has left them depressed, frustrated, and less confident in their ability to mother.

We must walk that fine line between actively advocating for lactation-friendly hospitals and work environments and supporting mothers who, due to circumstances beyond their control, can’t meet the expectations we have created for them.

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.”

 

Our first daughter was born during my last year in medical school, and our second was born as I was finishing my second year in residency. Seeing those two little darlings grow and develop was a critical supplement to my pediatric training. And, watching my wife initially struggle and then succeed with breastfeeding provided a very personal experience and education about lactation that my interactions in the hospital and outpatient clinics didn’t offer.

We considered ourselves lucky because my wife wasn’t facing the additional challenge of returning to an out-of-the-home job. However, our good fortune did not confer immunity against the anxiety, insecurity, discomfort, and sleep deprivation–induced frustrations of breastfeeding. Watching my wife navigate the choppy waters of lactation certainly influenced my approach to counseling new mothers over my subsequent 4 decades of practice. I think I was a more sympathetic and realistic adviser based on my first-hand observations.

©Lev Olkha/iStockphoto.com

A recent article in the AAP News addresses this relationship between physicians’ personal experiences with breastfeeding and their clinical interactions with the mothers in their practices (“Facing barriers to breastfeeding may affect physicians’ advocacy for patients,” February 2018). The authors refer to a study in the Journal of Human Lactation reporting that in the group of 927 pediatric trainees who were surveyed, of which 421 had children and 346 breastfed their children, “1 in 4 did not meet their breastfeeding duration goal, and 1 in 3 did not meet their goal for extended breastfeeding,” which was 6 months (J Hum Lact. 2015 May;31[2]:240-8). Twenty-five percent either did not have access to or were not aware of a private room where they could express milk or breastfeed. The resulting failure left the trainees feeling frustrated, depressed, and devastated. More than 90% of the respondents felt that their experiences affected their interactions with mothers in their practices.

In a different survey of American Academy of Pediatrics fellows, more of the 832 pediatricians responding reported having had a personal experience with breastfeeding in 2014 than of the 620 responding in 1995 (68% vs. 42%). However, it is interesting that fewer of the respondents in 2014 felt that any mother can succeed at breastfeeding (predicted value = 70% in 1995, PV = 56% in 2014; P less than .05), and fewer in 2014 believed that the advantages of breastfeeding outweighed the difficulties than among those surveyed in 1995 (PV = 70% in 1995, PV = 50% in 2014; P less than .05) (Pediatrics. 2017 Oct;140[4]. pii: e20171229). These results suggest that, as more pediatricians gained personal experience with breastfeeding, more may have realized that the American Academy of Pediatrics recommendations for breastfeeding are unrealistic and may contribute to the negative experiences of some women, including pediatric trainees.

An implied assumption in the AAP News article is that a pediatrician who has had a negative breastfeeding experience is less likely to be a strong advocate for breastfeeding. I would argue that a pediatrician who has witnessed or personally experienced difficulties is more likely to be a sympathetic and realistic advocate of breastfeeding.

Of course, my argument begs the question of exactly for what and for whom we are advocating. The quick reflex answer might be that, of course we are advocating for children because we have data supporting the benefits for them of exclusive breastfeeding for the first 6 months and extended breastfeeding for 1 year. However, many of us who have practiced pediatrics for more than a couple of decades have observed ample anecdotal evidence that overzealous advocacy for the current breastfeeding guidelines can result in casualties among women whose “failure” has left them depressed, frustrated, and less confident in their ability to mother.

We must walk that fine line between actively advocating for lactation-friendly hospitals and work environments and supporting mothers who, due to circumstances beyond their control, can’t meet the expectations we have created for them.

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.”

 

When we were invited to a family gathering to celebrate a 60th birthday, we expected to hear an abundance of news about grandchildren. They are natural, and seldom controversial, topics of discussion. If there is a child still waiting in utero and destined to be the first grandchild on one or both sides of the family, the impending adventure in parenthood will dominate the conversation.

To our great surprise, despite the presence of one very pregnant young woman, who in 6 weeks would be giving birth to the first grandchild in my nephew’s family, my wife and I can recall only one brief dialogue in which I was asked about how one might go about selecting a pediatrician.

Stockbyte/Thinkstock

There were no complaints about how the mother-to-be was sleeping or eating or ambulating. There were no descriptions of the color scheme and decor in the nursery – or the plans for day care – or how expensive and complicated car seats and strollers had become. Taking a cue from the young woman’s matter-of-fact attitude toward her pregnancy, the older women in the room showed amazing restraint by not swapping tales of their obstetrical adventures. The conversation ranged far and wide from football to failed recipes for chocolate cake, while the gravid uterus rested comfortably on its owner’s lap like the proverbial elephant in the room.

I’m not sure why the blessed event to come was being ignored, but I found the oversight unusual and refreshing. It is possible that there had been so much hype about the pregnancy on her side of the family that the couple relished its absence from the birthday party’s topics for discussion.

In the spirit of full disclosure, I must add that, as a result of my frequent claims of ignorance when asked about medically related topics, I am often referred to by the extended family as “Dr. I-Don’t-Know.” It may be that my presence influenced the conversation, but regardless of the reason, I was impressed with the ease at which this couple was approaching the birth of their first child.

I am sure they harbor some anxieties, and I am sure they have listened to some horror stories from their peers about sleep and breastfeeding problems. They are bright people who acknowledge that they are going to encounter some bumps along the road of parenthood. However, they seem to be immune to the epidemic of anxiety that for decades has been sweeping over cohorts of North Americans entering their family-building years.

Generations of young, seemingly intelligent people have lost their confidence in being able to do what should come naturally. They are ravenous consumers of information about how they should be parenting. And I admit that I have tried to capitalize on their insecurity by writing several books of advice for parents. Of course, I always have hoped that in time my readers probably will realize that while there are lots of ways to do it poorly, there is no best way to parent.

The young couple my wife and I encountered are just as clueless about what parenthood has in store as their anxiety-driven peers are. The difference is that they are enjoying their pregnancy in blissful ignorance buffered by their refreshing confidence that, however they do it, they will be doing it naturally.
 

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.”

 

When we were invited to a family gathering to celebrate a 60th birthday, we expected to hear an abundance of news about grandchildren. They are natural, and seldom controversial, topics of discussion. If there is a child still waiting in utero and destined to be the first grandchild on one or both sides of the family, the impending adventure in parenthood will dominate the conversation.

To our great surprise, despite the presence of one very pregnant young woman, who in 6 weeks would be giving birth to the first grandchild in my nephew’s family, my wife and I can recall only one brief dialogue in which I was asked about how one might go about selecting a pediatrician.

Stockbyte/Thinkstock

There were no complaints about how the mother-to-be was sleeping or eating or ambulating. There were no descriptions of the color scheme and decor in the nursery – or the plans for day care – or how expensive and complicated car seats and strollers had become. Taking a cue from the young woman’s matter-of-fact attitude toward her pregnancy, the older women in the room showed amazing restraint by not swapping tales of their obstetrical adventures. The conversation ranged far and wide from football to failed recipes for chocolate cake, while the gravid uterus rested comfortably on its owner’s lap like the proverbial elephant in the room.

I’m not sure why the blessed event to come was being ignored, but I found the oversight unusual and refreshing. It is possible that there had been so much hype about the pregnancy on her side of the family that the couple relished its absence from the birthday party’s topics for discussion.

In the spirit of full disclosure, I must add that, as a result of my frequent claims of ignorance when asked about medically related topics, I am often referred to by the extended family as “Dr. I-Don’t-Know.” It may be that my presence influenced the conversation, but regardless of the reason, I was impressed with the ease at which this couple was approaching the birth of their first child.

I am sure they harbor some anxieties, and I am sure they have listened to some horror stories from their peers about sleep and breastfeeding problems. They are bright people who acknowledge that they are going to encounter some bumps along the road of parenthood. However, they seem to be immune to the epidemic of anxiety that for decades has been sweeping over cohorts of North Americans entering their family-building years.

Generations of young, seemingly intelligent people have lost their confidence in being able to do what should come naturally. They are ravenous consumers of information about how they should be parenting. And I admit that I have tried to capitalize on their insecurity by writing several books of advice for parents. Of course, I always have hoped that in time my readers probably will realize that while there are lots of ways to do it poorly, there is no best way to parent.

The young couple my wife and I encountered are just as clueless about what parenthood has in store as their anxiety-driven peers are. The difference is that they are enjoying their pregnancy in blissful ignorance buffered by their refreshing confidence that, however they do it, they will be doing it naturally.
 

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.”

 

When we were invited to a family gathering to celebrate a 60th birthday, we expected to hear an abundance of news about grandchildren. They are natural, and seldom controversial, topics of discussion. If there is a child still waiting in utero and destined to be the first grandchild on one or both sides of the family, the impending adventure in parenthood will dominate the conversation.

To our great surprise, despite the presence of one very pregnant young woman, who in 6 weeks would be giving birth to the first grandchild in my nephew’s family, my wife and I can recall only one brief dialogue in which I was asked about how one might go about selecting a pediatrician.

Stockbyte/Thinkstock

There were no complaints about how the mother-to-be was sleeping or eating or ambulating. There were no descriptions of the color scheme and decor in the nursery – or the plans for day care – or how expensive and complicated car seats and strollers had become. Taking a cue from the young woman’s matter-of-fact attitude toward her pregnancy, the older women in the room showed amazing restraint by not swapping tales of their obstetrical adventures. The conversation ranged far and wide from football to failed recipes for chocolate cake, while the gravid uterus rested comfortably on its owner’s lap like the proverbial elephant in the room.

I’m not sure why the blessed event to come was being ignored, but I found the oversight unusual and refreshing. It is possible that there had been so much hype about the pregnancy on her side of the family that the couple relished its absence from the birthday party’s topics for discussion.

In the spirit of full disclosure, I must add that, as a result of my frequent claims of ignorance when asked about medically related topics, I am often referred to by the extended family as “Dr. I-Don’t-Know.” It may be that my presence influenced the conversation, but regardless of the reason, I was impressed with the ease at which this couple was approaching the birth of their first child.

I am sure they harbor some anxieties, and I am sure they have listened to some horror stories from their peers about sleep and breastfeeding problems. They are bright people who acknowledge that they are going to encounter some bumps along the road of parenthood. However, they seem to be immune to the epidemic of anxiety that for decades has been sweeping over cohorts of North Americans entering their family-building years.

Generations of young, seemingly intelligent people have lost their confidence in being able to do what should come naturally. They are ravenous consumers of information about how they should be parenting. And I admit that I have tried to capitalize on their insecurity by writing several books of advice for parents. Of course, I always have hoped that in time my readers probably will realize that while there are lots of ways to do it poorly, there is no best way to parent.

The young couple my wife and I encountered are just as clueless about what parenthood has in store as their anxiety-driven peers are. The difference is that they are enjoying their pregnancy in blissful ignorance buffered by their refreshing confidence that, however they do it, they will be doing it naturally.
 

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.”

 

If you were born in or after the 1970s, it is very likely that you have never watched a television show on a black and white set. Although the roots of its technology extend well back into the early 20th century, the first color broadcast on a national television network didn’t occur until 1954 with NBC’s coverage of the Tournament of Roses Parade.

When we compare the popularization of color television with the rapid pace at which we adopt new technology today, the popularization of color TV was glacial. In large part because of their expense, sales of color sets did not surpass black and white sets until 1972. Our family lagged behind the curve and finally caved in and junked our black and white television around 1977.

The observable change in our viewing behavior was dramatic. While programming in black and white was interesting, the color images were magnetic. We were drawn by the visual excitement and stimulation that color offered, and our family’s viewing standards took a precipitous dip. We seemed to watch anything that was colorful and moved. The quality of the content took a back seat. Viewing in color seemed to require much less cognitive effort. Ironically what attracted our attention allowed us to invest less energy in paying attention.

As a regular reader of Letters From Maine, you know that I am convinced that sleep deprivation is a major contributor to the emergence of the ADHD phenomenon. However, I can make a similar argument that the introduction of color television is an equally potent coconspirator or confounder. The magnetism inherent in a moving color image can tempt even the most health conscious among us to stay well past a brain-friendly bedtime. The invention of the electric light may have gotten the ball rolling, but the ubiquity of moving electronic color images has certainly greased what was already a very slippery slope into an abyss of unhealthy sleep habits.

©iStock/ThinkStockPhotos.com

In the last decade, we have put this eye candy of color television literally into the hands of very small children in the form of smartphones and tablets. Whether the power of electronic color images that I have referred to as magnetism can qualify as a true addiction is currently being investigated. However, anecdotal evidence of the attention grabbing power of these devices for children of all ages is overwhelming.

There are those who argue that smartphones and tablets can open a world of creative opportunities for even very young children. And, it is obvious that parents are struggling to find a balance as they try to decide when, where, and how often to allow their infants and toddlers access to handheld electronic devices.

Recently there has been much finger-pointing at the developers and manufacturers of smartphones and tablets. How can any company with a social conscience sell a product with such dangerous attractive potential for children without providing safeguards? Isn’t it like selling a swimming pool without a gated fence?

Of course the answer to this question goes to the heart of how our society views its responsibility to protect its children. Regardless of who makes the rules and how the responsibility is assigned, it is still the child’s parents who must make sure that the gate is locked.

I recently encountered a newspaper article describing a clever strategy that might make the job of policing handheld electronic devices much easier for concerned parents (Is the Answer to Phone Addiction a Worse Phone? by Nellie Bowles, The New York Times, Jan. 12, 2018). The author describes a simple maneuver in the settings of your device that will allow you to shift the screen image from the stimulating colors to which you are accustomed to shades of gray. Apparently, there is more than a little neuroscience evidence that supports my anecdotal evidence that taking out the color will make the screens much less attractive for children … and adults. It’s certainly worth a try.

 

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.”

 

If you were born in or after the 1970s, it is very likely that you have never watched a television show on a black and white set. Although the roots of its technology extend well back into the early 20th century, the first color broadcast on a national television network didn’t occur until 1954 with NBC’s coverage of the Tournament of Roses Parade.

When we compare the popularization of color television with the rapid pace at which we adopt new technology today, the popularization of color TV was glacial. In large part because of their expense, sales of color sets did not surpass black and white sets until 1972. Our family lagged behind the curve and finally caved in and junked our black and white television around 1977.

The observable change in our viewing behavior was dramatic. While programming in black and white was interesting, the color images were magnetic. We were drawn by the visual excitement and stimulation that color offered, and our family’s viewing standards took a precipitous dip. We seemed to watch anything that was colorful and moved. The quality of the content took a back seat. Viewing in color seemed to require much less cognitive effort. Ironically what attracted our attention allowed us to invest less energy in paying attention.

As a regular reader of Letters From Maine, you know that I am convinced that sleep deprivation is a major contributor to the emergence of the ADHD phenomenon. However, I can make a similar argument that the introduction of color television is an equally potent coconspirator or confounder. The magnetism inherent in a moving color image can tempt even the most health conscious among us to stay well past a brain-friendly bedtime. The invention of the electric light may have gotten the ball rolling, but the ubiquity of moving electronic color images has certainly greased what was already a very slippery slope into an abyss of unhealthy sleep habits.

©iStock/ThinkStockPhotos.com

In the last decade, we have put this eye candy of color television literally into the hands of very small children in the form of smartphones and tablets. Whether the power of electronic color images that I have referred to as magnetism can qualify as a true addiction is currently being investigated. However, anecdotal evidence of the attention grabbing power of these devices for children of all ages is overwhelming.

There are those who argue that smartphones and tablets can open a world of creative opportunities for even very young children. And, it is obvious that parents are struggling to find a balance as they try to decide when, where, and how often to allow their infants and toddlers access to handheld electronic devices.

Recently there has been much finger-pointing at the developers and manufacturers of smartphones and tablets. How can any company with a social conscience sell a product with such dangerous attractive potential for children without providing safeguards? Isn’t it like selling a swimming pool without a gated fence?

Of course the answer to this question goes to the heart of how our society views its responsibility to protect its children. Regardless of who makes the rules and how the responsibility is assigned, it is still the child’s parents who must make sure that the gate is locked.

I recently encountered a newspaper article describing a clever strategy that might make the job of policing handheld electronic devices much easier for concerned parents (Is the Answer to Phone Addiction a Worse Phone? by Nellie Bowles, The New York Times, Jan. 12, 2018). The author describes a simple maneuver in the settings of your device that will allow you to shift the screen image from the stimulating colors to which you are accustomed to shades of gray. Apparently, there is more than a little neuroscience evidence that supports my anecdotal evidence that taking out the color will make the screens much less attractive for children … and adults. It’s certainly worth a try.

 

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.”

 

If you were born in or after the 1970s, it is very likely that you have never watched a television show on a black and white set. Although the roots of its technology extend well back into the early 20th century, the first color broadcast on a national television network didn’t occur until 1954 with NBC’s coverage of the Tournament of Roses Parade.

When we compare the popularization of color television with the rapid pace at which we adopt new technology today, the popularization of color TV was glacial. In large part because of their expense, sales of color sets did not surpass black and white sets until 1972. Our family lagged behind the curve and finally caved in and junked our black and white television around 1977.

The observable change in our viewing behavior was dramatic. While programming in black and white was interesting, the color images were magnetic. We were drawn by the visual excitement and stimulation that color offered, and our family’s viewing standards took a precipitous dip. We seemed to watch anything that was colorful and moved. The quality of the content took a back seat. Viewing in color seemed to require much less cognitive effort. Ironically what attracted our attention allowed us to invest less energy in paying attention.

As a regular reader of Letters From Maine, you know that I am convinced that sleep deprivation is a major contributor to the emergence of the ADHD phenomenon. However, I can make a similar argument that the introduction of color television is an equally potent coconspirator or confounder. The magnetism inherent in a moving color image can tempt even the most health conscious among us to stay well past a brain-friendly bedtime. The invention of the electric light may have gotten the ball rolling, but the ubiquity of moving electronic color images has certainly greased what was already a very slippery slope into an abyss of unhealthy sleep habits.

©iStock/ThinkStockPhotos.com

In the last decade, we have put this eye candy of color television literally into the hands of very small children in the form of smartphones and tablets. Whether the power of electronic color images that I have referred to as magnetism can qualify as a true addiction is currently being investigated. However, anecdotal evidence of the attention grabbing power of these devices for children of all ages is overwhelming.

There are those who argue that smartphones and tablets can open a world of creative opportunities for even very young children. And, it is obvious that parents are struggling to find a balance as they try to decide when, where, and how often to allow their infants and toddlers access to handheld electronic devices.

Recently there has been much finger-pointing at the developers and manufacturers of smartphones and tablets. How can any company with a social conscience sell a product with such dangerous attractive potential for children without providing safeguards? Isn’t it like selling a swimming pool without a gated fence?

Of course the answer to this question goes to the heart of how our society views its responsibility to protect its children. Regardless of who makes the rules and how the responsibility is assigned, it is still the child’s parents who must make sure that the gate is locked.

I recently encountered a newspaper article describing a clever strategy that might make the job of policing handheld electronic devices much easier for concerned parents (Is the Answer to Phone Addiction a Worse Phone? by Nellie Bowles, The New York Times, Jan. 12, 2018). The author describes a simple maneuver in the settings of your device that will allow you to shift the screen image from the stimulating colors to which you are accustomed to shades of gray. Apparently, there is more than a little neuroscience evidence that supports my anecdotal evidence that taking out the color will make the screens much less attractive for children … and adults. It’s certainly worth a try.

 

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.”

 

“She will eat when she is hungry.” That in so many words is the mantra of grandparents blessed with experience and common sense and of most pediatricians when consulting parents challenged with a picky eater. From birth, children understand the simple equation that to survive they must eat. With rare exception, the motivating power of hunger can be leveraged for success even with infants who have spent their first months relying on enteral feedings. I have written an entire book based solely on the premise that if you present a young child food she will eat it ... eventually (“Coping With a Picky Eater: A Guide for the Perplexed Parent” New York: Simon and Schuster, 1998).

But if we reverse the words to read, “When she is eating, she is hungry,” do we have an equally valid observation? I think we have ample evidence that it is not.

Wavebreakmedia/Thinkstock

I recently encountered an anecdote in one of the New York Times op-ed pieces by Perri Klass, MD, that got me thinking more broadly about the perception of hunger and its power to motivate (“Do parents make kids fat?” the New York Times, Jan. 8, 2018). Dr. Klass relates a story of an obesity specialist who herself had struggled with obesity. Despite her careful attention to everything she had learned about obesity management and breastfeeding, this woman was unprepared for giving birth to an infant who was “instantly a very dramatically hungry baby.”

The result was a year-long odyssey of pumping that included consultations with five different lactation consultants in the first frustrating month and a half. She eventually received some comforting advice from a pediatrician who reassured her that there was little research to guide her and to “just feed him; trust your instincts.”

While it is unfortunately true that there is very little good science we can fall back on when counseling women who are struggling with breastfeeding, I wonder about the wisdom of telling this mother to trust her instincts. I guess my hesitancy is based on 40 years of primary care pediatrics in which I could generally count on the instincts of young children, but their parents’ not so much. While maternal intuition is generally superior to the paternal version, I am hesitant to rely totally on either when facing a clinical dilemma such as defining hunger.

Is a fussy infant hungry because he seems to be comforted only by a bottle or breast? What about the fussy baby who is comforted by just a pacifier? What is the difference? There are several explanations, but it will require introducing the concept of nutrition deficiency.

Most babies who are satisfied with just a nipple, be it silicone or flesh, simply find sucking a comfort measure. A few, and I am sure you have seen some of them, are overly patient. They seem to be saying, “I need the calories, but you’re a good mom and I enjoy sucking. I can wait. Some day, you may make more milk or give me a bottle.” In the worst-case scenarios, their patience leaves these babies so nutritionally deficient that they can slip into apathy and die.

On the other end of the spectrum are infants who love to suck so much that they will ignore (or maybe lack) their own satiety center. They may be fussy for some other reason than hunger, most likely sleep deprivation, and will suck and swallow to comfort themselves even though they have met their nutritional needs. The surplus milk or formula is converted to unhealthy weight or is misdiagnosed as “reflux.” Could this phenomenon have a genetic basis? Has the mother in Dr. Klass’ scenario shared an inheritable problem with satiety with her infant?

There are no easy answers. As pediatricians, our job is to sort out those fussy “hungry” babies whose behavior means they are overtired from those who are nutritionally deficient, from those with a dysfunctional satiety center. Making the differentiation is difficult but much easier than helping parents ignore one of their instincts.
 

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.” Email him at [email protected].

 

“She will eat when she is hungry.” That in so many words is the mantra of grandparents blessed with experience and common sense and of most pediatricians when consulting parents challenged with a picky eater. From birth, children understand the simple equation that to survive they must eat. With rare exception, the motivating power of hunger can be leveraged for success even with infants who have spent their first months relying on enteral feedings. I have written an entire book based solely on the premise that if you present a young child food she will eat it ... eventually (“Coping With a Picky Eater: A Guide for the Perplexed Parent” New York: Simon and Schuster, 1998).

But if we reverse the words to read, “When she is eating, she is hungry,” do we have an equally valid observation? I think we have ample evidence that it is not.

Wavebreakmedia/Thinkstock

I recently encountered an anecdote in one of the New York Times op-ed pieces by Perri Klass, MD, that got me thinking more broadly about the perception of hunger and its power to motivate (“Do parents make kids fat?” the New York Times, Jan. 8, 2018). Dr. Klass relates a story of an obesity specialist who herself had struggled with obesity. Despite her careful attention to everything she had learned about obesity management and breastfeeding, this woman was unprepared for giving birth to an infant who was “instantly a very dramatically hungry baby.”

The result was a year-long odyssey of pumping that included consultations with five different lactation consultants in the first frustrating month and a half. She eventually received some comforting advice from a pediatrician who reassured her that there was little research to guide her and to “just feed him; trust your instincts.”

While it is unfortunately true that there is very little good science we can fall back on when counseling women who are struggling with breastfeeding, I wonder about the wisdom of telling this mother to trust her instincts. I guess my hesitancy is based on 40 years of primary care pediatrics in which I could generally count on the instincts of young children, but their parents’ not so much. While maternal intuition is generally superior to the paternal version, I am hesitant to rely totally on either when facing a clinical dilemma such as defining hunger.

Is a fussy infant hungry because he seems to be comforted only by a bottle or breast? What about the fussy baby who is comforted by just a pacifier? What is the difference? There are several explanations, but it will require introducing the concept of nutrition deficiency.

Most babies who are satisfied with just a nipple, be it silicone or flesh, simply find sucking a comfort measure. A few, and I am sure you have seen some of them, are overly patient. They seem to be saying, “I need the calories, but you’re a good mom and I enjoy sucking. I can wait. Some day, you may make more milk or give me a bottle.” In the worst-case scenarios, their patience leaves these babies so nutritionally deficient that they can slip into apathy and die.

On the other end of the spectrum are infants who love to suck so much that they will ignore (or maybe lack) their own satiety center. They may be fussy for some other reason than hunger, most likely sleep deprivation, and will suck and swallow to comfort themselves even though they have met their nutritional needs. The surplus milk or formula is converted to unhealthy weight or is misdiagnosed as “reflux.” Could this phenomenon have a genetic basis? Has the mother in Dr. Klass’ scenario shared an inheritable problem with satiety with her infant?

There are no easy answers. As pediatricians, our job is to sort out those fussy “hungry” babies whose behavior means they are overtired from those who are nutritionally deficient, from those with a dysfunctional satiety center. Making the differentiation is difficult but much easier than helping parents ignore one of their instincts.
 

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.” Email him at [email protected].

 

“She will eat when she is hungry.” That in so many words is the mantra of grandparents blessed with experience and common sense and of most pediatricians when consulting parents challenged with a picky eater. From birth, children understand the simple equation that to survive they must eat. With rare exception, the motivating power of hunger can be leveraged for success even with infants who have spent their first months relying on enteral feedings. I have written an entire book based solely on the premise that if you present a young child food she will eat it ... eventually (“Coping With a Picky Eater: A Guide for the Perplexed Parent” New York: Simon and Schuster, 1998).

But if we reverse the words to read, “When she is eating, she is hungry,” do we have an equally valid observation? I think we have ample evidence that it is not.

Wavebreakmedia/Thinkstock

I recently encountered an anecdote in one of the New York Times op-ed pieces by Perri Klass, MD, that got me thinking more broadly about the perception of hunger and its power to motivate (“Do parents make kids fat?” the New York Times, Jan. 8, 2018). Dr. Klass relates a story of an obesity specialist who herself had struggled with obesity. Despite her careful attention to everything she had learned about obesity management and breastfeeding, this woman was unprepared for giving birth to an infant who was “instantly a very dramatically hungry baby.”

The result was a year-long odyssey of pumping that included consultations with five different lactation consultants in the first frustrating month and a half. She eventually received some comforting advice from a pediatrician who reassured her that there was little research to guide her and to “just feed him; trust your instincts.”

While it is unfortunately true that there is very little good science we can fall back on when counseling women who are struggling with breastfeeding, I wonder about the wisdom of telling this mother to trust her instincts. I guess my hesitancy is based on 40 years of primary care pediatrics in which I could generally count on the instincts of young children, but their parents’ not so much. While maternal intuition is generally superior to the paternal version, I am hesitant to rely totally on either when facing a clinical dilemma such as defining hunger.

Is a fussy infant hungry because he seems to be comforted only by a bottle or breast? What about the fussy baby who is comforted by just a pacifier? What is the difference? There are several explanations, but it will require introducing the concept of nutrition deficiency.

Most babies who are satisfied with just a nipple, be it silicone or flesh, simply find sucking a comfort measure. A few, and I am sure you have seen some of them, are overly patient. They seem to be saying, “I need the calories, but you’re a good mom and I enjoy sucking. I can wait. Some day, you may make more milk or give me a bottle.” In the worst-case scenarios, their patience leaves these babies so nutritionally deficient that they can slip into apathy and die.

On the other end of the spectrum are infants who love to suck so much that they will ignore (or maybe lack) their own satiety center. They may be fussy for some other reason than hunger, most likely sleep deprivation, and will suck and swallow to comfort themselves even though they have met their nutritional needs. The surplus milk or formula is converted to unhealthy weight or is misdiagnosed as “reflux.” Could this phenomenon have a genetic basis? Has the mother in Dr. Klass’ scenario shared an inheritable problem with satiety with her infant?

There are no easy answers. As pediatricians, our job is to sort out those fussy “hungry” babies whose behavior means they are overtired from those who are nutritionally deficient, from those with a dysfunctional satiety center. Making the differentiation is difficult but much easier than helping parents ignore one of their instincts.
 

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.” Email him at [email protected].

 

“In medicine, a lack of experience may not actually be a bad thing.” The words leapt off my tablet, and my blood pressure hit the stratosphere. How could a 30-year-old physician who is still doing his cardiology fellowship have the nerve to take a cheap shot at one of the cornerstones of my identity? (“For Doctors, Age May Be More Than a Number,” by Haider Javed Warraich, The New York Times, Jan. 6, 2018.) My reputation as a skilled pediatrician was built on the breadth and depth of my clinical experience. In the first 30 years of my professional career, I had participated in more than 300,000 patient encounters. Wasn’t that effort good for something?

Darrin Klimek/Thinkstock

I stopped reading, set the tablet down, and went for a brisk walk around the neighborhood, hoping to get my emotions under control before reading on. Refreshed and tempered by the subzero air, I read on and discovered that Dr. Warraich had done his homework and offered some evidence to support his claim that, at least in medicine, experience may be overvalued.

He wrote that in a study of hospitalists (BMJ. 2017;357:j1797), the patient death rate increased steadily from 10.8% for physicians younger than 40 years to 12.1% for those 6o years and older, except those physicians treating a high volume of patients. He also cites a study in which the authors analyzed 62 studies of quality of care. The investigators found that slightly more than half of the studies “report decreasing performance with increasing years in practice” (Ann Int Med. 2005 Feb 15;142[4]:260-73).

Still in a defensive mode, I decided to chase down the references and take a closer look. In the study demonstrating patient mortality increasing with physician age, we must consider that these physicians were hospitalists and the patients were elderly. The observations may not be applicable to those seeing younger patients in a primary care office setting.

Another caveat listed by the authors is that the association between increasing patient mortality with increasing physician age did not hold true “among physicians with high volumes of patients.” As a high-volume practitioner myself, I found this comforting. It may be that there is some threshold effect in which a little experience is a negative but a ton of experience is a plus. Experience can teach efficiency. But, of course, efficiency doesn’t always equate with quality.

The study citing a decline in quality of care with physician age is a bit more troublesome. However, it may be that, rightly or wrongly, older physicians who have seen the tide go in and out enough times are more hesitant to accept and adhere to “evidence-based” quality measures that they see as ephemeral.

It was Dr. Warraich’s citation from the journal Cancer that I had the most difficult time rationalizing. This study found that younger physicians were more likely to discuss end of life issues with patients (Cancer. 2010 Feb 15;116[4]:998-1006). I suspect this is a valid observation as I have always struggled with discussing subjects such as sexuality and end of life issues with patients.

After what for me was an inflammatory opening, Dr. Warraich’s article closes with the observation that “mentorship is a two-way street.” Any physician who has worked with medical students and inquisitive house officers realizes that our surplus of experience always can stand to gain a little refreshing from those who have little of their own.
 

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.”

 

“In medicine, a lack of experience may not actually be a bad thing.” The words leapt off my tablet, and my blood pressure hit the stratosphere. How could a 30-year-old physician who is still doing his cardiology fellowship have the nerve to take a cheap shot at one of the cornerstones of my identity? (“For Doctors, Age May Be More Than a Number,” by Haider Javed Warraich, The New York Times, Jan. 6, 2018.) My reputation as a skilled pediatrician was built on the breadth and depth of my clinical experience. In the first 30 years of my professional career, I had participated in more than 300,000 patient encounters. Wasn’t that effort good for something?

Darrin Klimek/Thinkstock

I stopped reading, set the tablet down, and went for a brisk walk around the neighborhood, hoping to get my emotions under control before reading on. Refreshed and tempered by the subzero air, I read on and discovered that Dr. Warraich had done his homework and offered some evidence to support his claim that, at least in medicine, experience may be overvalued.

He wrote that in a study of hospitalists (BMJ. 2017;357:j1797), the patient death rate increased steadily from 10.8% for physicians younger than 40 years to 12.1% for those 6o years and older, except those physicians treating a high volume of patients. He also cites a study in which the authors analyzed 62 studies of quality of care. The investigators found that slightly more than half of the studies “report decreasing performance with increasing years in practice” (Ann Int Med. 2005 Feb 15;142[4]:260-73).

Still in a defensive mode, I decided to chase down the references and take a closer look. In the study demonstrating patient mortality increasing with physician age, we must consider that these physicians were hospitalists and the patients were elderly. The observations may not be applicable to those seeing younger patients in a primary care office setting.

Another caveat listed by the authors is that the association between increasing patient mortality with increasing physician age did not hold true “among physicians with high volumes of patients.” As a high-volume practitioner myself, I found this comforting. It may be that there is some threshold effect in which a little experience is a negative but a ton of experience is a plus. Experience can teach efficiency. But, of course, efficiency doesn’t always equate with quality.

The study citing a decline in quality of care with physician age is a bit more troublesome. However, it may be that, rightly or wrongly, older physicians who have seen the tide go in and out enough times are more hesitant to accept and adhere to “evidence-based” quality measures that they see as ephemeral.

It was Dr. Warraich’s citation from the journal Cancer that I had the most difficult time rationalizing. This study found that younger physicians were more likely to discuss end of life issues with patients (Cancer. 2010 Feb 15;116[4]:998-1006). I suspect this is a valid observation as I have always struggled with discussing subjects such as sexuality and end of life issues with patients.

After what for me was an inflammatory opening, Dr. Warraich’s article closes with the observation that “mentorship is a two-way street.” Any physician who has worked with medical students and inquisitive house officers realizes that our surplus of experience always can stand to gain a little refreshing from those who have little of their own.
 

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.”

 

“In medicine, a lack of experience may not actually be a bad thing.” The words leapt off my tablet, and my blood pressure hit the stratosphere. How could a 30-year-old physician who is still doing his cardiology fellowship have the nerve to take a cheap shot at one of the cornerstones of my identity? (“For Doctors, Age May Be More Than a Number,” by Haider Javed Warraich, The New York Times, Jan. 6, 2018.) My reputation as a skilled pediatrician was built on the breadth and depth of my clinical experience. In the first 30 years of my professional career, I had participated in more than 300,000 patient encounters. Wasn’t that effort good for something?

Darrin Klimek/Thinkstock

I stopped reading, set the tablet down, and went for a brisk walk around the neighborhood, hoping to get my emotions under control before reading on. Refreshed and tempered by the subzero air, I read on and discovered that Dr. Warraich had done his homework and offered some evidence to support his claim that, at least in medicine, experience may be overvalued.

He wrote that in a study of hospitalists (BMJ. 2017;357:j1797), the patient death rate increased steadily from 10.8% for physicians younger than 40 years to 12.1% for those 6o years and older, except those physicians treating a high volume of patients. He also cites a study in which the authors analyzed 62 studies of quality of care. The investigators found that slightly more than half of the studies “report decreasing performance with increasing years in practice” (Ann Int Med. 2005 Feb 15;142[4]:260-73).

Still in a defensive mode, I decided to chase down the references and take a closer look. In the study demonstrating patient mortality increasing with physician age, we must consider that these physicians were hospitalists and the patients were elderly. The observations may not be applicable to those seeing younger patients in a primary care office setting.

Another caveat listed by the authors is that the association between increasing patient mortality with increasing physician age did not hold true “among physicians with high volumes of patients.” As a high-volume practitioner myself, I found this comforting. It may be that there is some threshold effect in which a little experience is a negative but a ton of experience is a plus. Experience can teach efficiency. But, of course, efficiency doesn’t always equate with quality.

The study citing a decline in quality of care with physician age is a bit more troublesome. However, it may be that, rightly or wrongly, older physicians who have seen the tide go in and out enough times are more hesitant to accept and adhere to “evidence-based” quality measures that they see as ephemeral.

It was Dr. Warraich’s citation from the journal Cancer that I had the most difficult time rationalizing. This study found that younger physicians were more likely to discuss end of life issues with patients (Cancer. 2010 Feb 15;116[4]:998-1006). I suspect this is a valid observation as I have always struggled with discussing subjects such as sexuality and end of life issues with patients.

After what for me was an inflammatory opening, Dr. Warraich’s article closes with the observation that “mentorship is a two-way street.” Any physician who has worked with medical students and inquisitive house officers realizes that our surplus of experience always can stand to gain a little refreshing from those who have little of their own.
 

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.”