Letters from Maine

A young couple already has decided to bring their as-yet-unborn child to your group. Now they are interviewing each member in hopes of finding a primary care physician who will best fit their expectations. Their second question for you is, “How do you feel about letting a baby cry itself to sleep?”

You sense that their question is a Rorschach test and a sneaky attempt to peer into what makes you tick. But let’s pretend for a moment that you are seized by a brain cramp and fail to do the obvious by turning the question around and asking them about how they feel about sleep training. Instead, you shoot from the hip. How would you respond?

Would you tell them that allowing a child to cry himself to sleep is neither dangerous nor cruel? Nor does it commit the child to a life of insecurity and emotional imbalance. In your opinion, if done correctly, it is usually the quickest and least painful way to help a child develop healthy sleep habits.

Or would you tell them that their child’s cry means that he needs something, and it is their responsibility to meet that need? That you believe letting a child cry himself to sleep is cruel and that it is better to let a child develop the skill of falling to sleep naturally at his own pace.

Because you neglected to first determine where these parents are coming from, regardless of which end of the spectrum you favor, your candid, nuance-free answer is likely to be a problem for somebody. If you revealed that you are a let-’em-cry proponent, the parents who were looking for a sensitive, child-centered pediatrician will quickly cross you off their list. However, if the parents choose you because you presented yourself as a let-nature-take-its-time pediatrician, they may have narrowed their options when their baby fails to settle in easily.

The challenge of how best to advise parents about infant sleep problems is a prime example of when practicing primary care medicine becomes an art. The answer to the let-’em-cry … or not dilemma is saturated with emotion and pretty much devoid of supporting scientific data. My gut, my personality, and 40 years of experience tell me that, more often than not, letting children cry themselves to sleep is the better approach. However, experience also has told me to keep my mouth shut when the topic of infant sleep is painted in the black-and-white question of let ‘em cry … or not.

The best approach is to learn as much as possible about the baby’s parents. Do they have similar or widely differing tolerances for a crying infant? I won’t really learn this until the parenting game has begun. Will I be able to convince these parents that, while it may be their responsibility to meet their crying child’s needs, one of those needs is the need to fall asleep? Or will I be wasting my time by trying to change their instincts?

Regardless of your own bias, your advice must be tailored to each individual family’s strengths and vulnerabilities, including the child’s temperament and the parents’ emotional resilience and tolerance for crying. Just as when we are counseling a mother who is nearing the end of her struggle with breastfeeding, a pediatrician must be prepared to become a chameleon and leave his or her bias behind.

One of the best strategies for avoiding that treacherous let-’em-cry … or not fork in the road is to promote good sleep habits from the beginning. When a baby is gaining weight, I encourage mothers to shorten feedings so that the baby finishes most feedings sated and drowsy but not fully asleep. I urge parents who find that a pacifier helps to use it only when the child is in his crib and to create a dim light, minimal-stimulation environment from around 7 p.m. to 7 a.m. By encouraging families to adopt these and other sleep-friendly practices early, I can often avoid revealing the ugly truth that, at my core, I am really a let-’em-cry guy.

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.”

A young couple already has decided to bring their as-yet-unborn child to your group. Now they are interviewing each member in hopes of finding a primary care physician who will best fit their expectations. Their second question for you is, “How do you feel about letting a baby cry itself to sleep?”

You sense that their question is a Rorschach test and a sneaky attempt to peer into what makes you tick. But let’s pretend for a moment that you are seized by a brain cramp and fail to do the obvious by turning the question around and asking them about how they feel about sleep training. Instead, you shoot from the hip. How would you respond?

Would you tell them that allowing a child to cry himself to sleep is neither dangerous nor cruel? Nor does it commit the child to a life of insecurity and emotional imbalance. In your opinion, if done correctly, it is usually the quickest and least painful way to help a child develop healthy sleep habits.

Or would you tell them that their child’s cry means that he needs something, and it is their responsibility to meet that need? That you believe letting a child cry himself to sleep is cruel and that it is better to let a child develop the skill of falling to sleep naturally at his own pace.

Because you neglected to first determine where these parents are coming from, regardless of which end of the spectrum you favor, your candid, nuance-free answer is likely to be a problem for somebody. If you revealed that you are a let-’em-cry proponent, the parents who were looking for a sensitive, child-centered pediatrician will quickly cross you off their list. However, if the parents choose you because you presented yourself as a let-nature-take-its-time pediatrician, they may have narrowed their options when their baby fails to settle in easily.

The challenge of how best to advise parents about infant sleep problems is a prime example of when practicing primary care medicine becomes an art. The answer to the let-’em-cry … or not dilemma is saturated with emotion and pretty much devoid of supporting scientific data. My gut, my personality, and 40 years of experience tell me that, more often than not, letting children cry themselves to sleep is the better approach. However, experience also has told me to keep my mouth shut when the topic of infant sleep is painted in the black-and-white question of let ‘em cry … or not.

The best approach is to learn as much as possible about the baby’s parents. Do they have similar or widely differing tolerances for a crying infant? I won’t really learn this until the parenting game has begun. Will I be able to convince these parents that, while it may be their responsibility to meet their crying child’s needs, one of those needs is the need to fall asleep? Or will I be wasting my time by trying to change their instincts?

Regardless of your own bias, your advice must be tailored to each individual family’s strengths and vulnerabilities, including the child’s temperament and the parents’ emotional resilience and tolerance for crying. Just as when we are counseling a mother who is nearing the end of her struggle with breastfeeding, a pediatrician must be prepared to become a chameleon and leave his or her bias behind.

One of the best strategies for avoiding that treacherous let-’em-cry … or not fork in the road is to promote good sleep habits from the beginning. When a baby is gaining weight, I encourage mothers to shorten feedings so that the baby finishes most feedings sated and drowsy but not fully asleep. I urge parents who find that a pacifier helps to use it only when the child is in his crib and to create a dim light, minimal-stimulation environment from around 7 p.m. to 7 a.m. By encouraging families to adopt these and other sleep-friendly practices early, I can often avoid revealing the ugly truth that, at my core, I am really a let-’em-cry guy.

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.”

A young couple already has decided to bring their as-yet-unborn child to your group. Now they are interviewing each member in hopes of finding a primary care physician who will best fit their expectations. Their second question for you is, “How do you feel about letting a baby cry itself to sleep?”

You sense that their question is a Rorschach test and a sneaky attempt to peer into what makes you tick. But let’s pretend for a moment that you are seized by a brain cramp and fail to do the obvious by turning the question around and asking them about how they feel about sleep training. Instead, you shoot from the hip. How would you respond?

Would you tell them that allowing a child to cry himself to sleep is neither dangerous nor cruel? Nor does it commit the child to a life of insecurity and emotional imbalance. In your opinion, if done correctly, it is usually the quickest and least painful way to help a child develop healthy sleep habits.

Or would you tell them that their child’s cry means that he needs something, and it is their responsibility to meet that need? That you believe letting a child cry himself to sleep is cruel and that it is better to let a child develop the skill of falling to sleep naturally at his own pace.

Because you neglected to first determine where these parents are coming from, regardless of which end of the spectrum you favor, your candid, nuance-free answer is likely to be a problem for somebody. If you revealed that you are a let-’em-cry proponent, the parents who were looking for a sensitive, child-centered pediatrician will quickly cross you off their list. However, if the parents choose you because you presented yourself as a let-nature-take-its-time pediatrician, they may have narrowed their options when their baby fails to settle in easily.

The challenge of how best to advise parents about infant sleep problems is a prime example of when practicing primary care medicine becomes an art. The answer to the let-’em-cry … or not dilemma is saturated with emotion and pretty much devoid of supporting scientific data. My gut, my personality, and 40 years of experience tell me that, more often than not, letting children cry themselves to sleep is the better approach. However, experience also has told me to keep my mouth shut when the topic of infant sleep is painted in the black-and-white question of let ‘em cry … or not.

The best approach is to learn as much as possible about the baby’s parents. Do they have similar or widely differing tolerances for a crying infant? I won’t really learn this until the parenting game has begun. Will I be able to convince these parents that, while it may be their responsibility to meet their crying child’s needs, one of those needs is the need to fall asleep? Or will I be wasting my time by trying to change their instincts?

Regardless of your own bias, your advice must be tailored to each individual family’s strengths and vulnerabilities, including the child’s temperament and the parents’ emotional resilience and tolerance for crying. Just as when we are counseling a mother who is nearing the end of her struggle with breastfeeding, a pediatrician must be prepared to become a chameleon and leave his or her bias behind.

One of the best strategies for avoiding that treacherous let-’em-cry … or not fork in the road is to promote good sleep habits from the beginning. When a baby is gaining weight, I encourage mothers to shorten feedings so that the baby finishes most feedings sated and drowsy but not fully asleep. I urge parents who find that a pacifier helps to use it only when the child is in his crib and to create a dim light, minimal-stimulation environment from around 7 p.m. to 7 a.m. By encouraging families to adopt these and other sleep-friendly practices early, I can often avoid revealing the ugly truth that, at my core, I am really a let-’em-cry guy.

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.”

A few weeks ago, Marilyn and I were left in charge of two of our grandchildren, 8 and 10 years old. The morning was overcast and drizzly, eliminating their first choice of going to the college athletic fields to practice their lacrosse skills. A game of Monopoly seemed like a good idea until it became obvious that someone was going to win and that another someone who doesn’t handle defeat very well was going to lose. So off we went to the bowling alley. As we pulled into the sparsely occupied parking lot, the ever-observant 8-year-old noted that almost all of the vehicles were vans.

As we checked in to rent our shoes, the explanation for the vans became clear. It turns out that on Thursday mornings, the bowling alley is the place to be if you are an adult with a mental disability in Brunswick, Maine.

Our grandchildren had a wonderful hour of bowling surrounded by the cacophony created by the several dozen adults with whom we were sharing the lanes. As my wife and I revisited our morning adventure that evening, we recalled how comfortable our grandchildren had been in the midst of a scenario that had the chaotic feel of a Hieronymus Bosch painting.

The explanation for their lack of discomfort lies in the fact that they have grown up in a time and in a town in which the individuals with chromosomal anomalies and birth injury are accepted and cared for in the community and not hidden away in an institution. Our grandchildren’s parents were born as this sea change was just beginning. In fact, when my son was born, I was moonlighting as the night emergency physician at an institution that housed a few hundred of these individuals, many of whom had disabilities similar to those of the folks with whom we had shared the bowling alley. It closed a few years later. And, by the time my son and his sisters entered middle school, they had become accustomed to having classmates with mental disabilities.

The next step in the evolution came when the children who had been “mainstreamed” grew too old for high school and began transitioning to the handful of small group homes that sprang up around the community. It was not always a smooth process and would not have happened without tireless pressure from their parents. Even today, funding and staffing problems continue. Despite initial concerns that some neighborhoods might resist the introduction of a group home, acceptance has not been a problem.

It has almost been a win-win situation. Our citizens with mental disabilities have a far richer life than they would have had in even the most progressive institution. And the rest of us have benefited by learning tolerance from having our challenged family members close by.

However, the transition from institutionalization to community-based support has not been without its downside, particularly for a small town like Brunswick, Maine. Federal and state mandates now place on the shoulders of the school a significant financial burden for the special services required by children with mental disabilities. Small communities with only a few students with disabilities can’t benefit from the economies of scale that allow larger school systems to staff their programs more efficiently and provide more specialized services. Smaller school districts can sometimes pool their resources. But if this solution necessitates transporting the students with mental disabilities out of their own school district to a central location, it runs the risk of robbing the other students, like my grandchildren, of an enriching experience that I wouldn’t want to see them lose.

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.”

A few weeks ago, Marilyn and I were left in charge of two of our grandchildren, 8 and 10 years old. The morning was overcast and drizzly, eliminating their first choice of going to the college athletic fields to practice their lacrosse skills. A game of Monopoly seemed like a good idea until it became obvious that someone was going to win and that another someone who doesn’t handle defeat very well was going to lose. So off we went to the bowling alley. As we pulled into the sparsely occupied parking lot, the ever-observant 8-year-old noted that almost all of the vehicles were vans.

As we checked in to rent our shoes, the explanation for the vans became clear. It turns out that on Thursday mornings, the bowling alley is the place to be if you are an adult with a mental disability in Brunswick, Maine.

Our grandchildren had a wonderful hour of bowling surrounded by the cacophony created by the several dozen adults with whom we were sharing the lanes. As my wife and I revisited our morning adventure that evening, we recalled how comfortable our grandchildren had been in the midst of a scenario that had the chaotic feel of a Hieronymus Bosch painting.

The explanation for their lack of discomfort lies in the fact that they have grown up in a time and in a town in which the individuals with chromosomal anomalies and birth injury are accepted and cared for in the community and not hidden away in an institution. Our grandchildren’s parents were born as this sea change was just beginning. In fact, when my son was born, I was moonlighting as the night emergency physician at an institution that housed a few hundred of these individuals, many of whom had disabilities similar to those of the folks with whom we had shared the bowling alley. It closed a few years later. And, by the time my son and his sisters entered middle school, they had become accustomed to having classmates with mental disabilities.

The next step in the evolution came when the children who had been “mainstreamed” grew too old for high school and began transitioning to the handful of small group homes that sprang up around the community. It was not always a smooth process and would not have happened without tireless pressure from their parents. Even today, funding and staffing problems continue. Despite initial concerns that some neighborhoods might resist the introduction of a group home, acceptance has not been a problem.

It has almost been a win-win situation. Our citizens with mental disabilities have a far richer life than they would have had in even the most progressive institution. And the rest of us have benefited by learning tolerance from having our challenged family members close by.

However, the transition from institutionalization to community-based support has not been without its downside, particularly for a small town like Brunswick, Maine. Federal and state mandates now place on the shoulders of the school a significant financial burden for the special services required by children with mental disabilities. Small communities with only a few students with disabilities can’t benefit from the economies of scale that allow larger school systems to staff their programs more efficiently and provide more specialized services. Smaller school districts can sometimes pool their resources. But if this solution necessitates transporting the students with mental disabilities out of their own school district to a central location, it runs the risk of robbing the other students, like my grandchildren, of an enriching experience that I wouldn’t want to see them lose.

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.”

A few weeks ago, Marilyn and I were left in charge of two of our grandchildren, 8 and 10 years old. The morning was overcast and drizzly, eliminating their first choice of going to the college athletic fields to practice their lacrosse skills. A game of Monopoly seemed like a good idea until it became obvious that someone was going to win and that another someone who doesn’t handle defeat very well was going to lose. So off we went to the bowling alley. As we pulled into the sparsely occupied parking lot, the ever-observant 8-year-old noted that almost all of the vehicles were vans.

As we checked in to rent our shoes, the explanation for the vans became clear. It turns out that on Thursday mornings, the bowling alley is the place to be if you are an adult with a mental disability in Brunswick, Maine.

Our grandchildren had a wonderful hour of bowling surrounded by the cacophony created by the several dozen adults with whom we were sharing the lanes. As my wife and I revisited our morning adventure that evening, we recalled how comfortable our grandchildren had been in the midst of a scenario that had the chaotic feel of a Hieronymus Bosch painting.

The explanation for their lack of discomfort lies in the fact that they have grown up in a time and in a town in which the individuals with chromosomal anomalies and birth injury are accepted and cared for in the community and not hidden away in an institution. Our grandchildren’s parents were born as this sea change was just beginning. In fact, when my son was born, I was moonlighting as the night emergency physician at an institution that housed a few hundred of these individuals, many of whom had disabilities similar to those of the folks with whom we had shared the bowling alley. It closed a few years later. And, by the time my son and his sisters entered middle school, they had become accustomed to having classmates with mental disabilities.

The next step in the evolution came when the children who had been “mainstreamed” grew too old for high school and began transitioning to the handful of small group homes that sprang up around the community. It was not always a smooth process and would not have happened without tireless pressure from their parents. Even today, funding and staffing problems continue. Despite initial concerns that some neighborhoods might resist the introduction of a group home, acceptance has not been a problem.

It has almost been a win-win situation. Our citizens with mental disabilities have a far richer life than they would have had in even the most progressive institution. And the rest of us have benefited by learning tolerance from having our challenged family members close by.

However, the transition from institutionalization to community-based support has not been without its downside, particularly for a small town like Brunswick, Maine. Federal and state mandates now place on the shoulders of the school a significant financial burden for the special services required by children with mental disabilities. Small communities with only a few students with disabilities can’t benefit from the economies of scale that allow larger school systems to staff their programs more efficiently and provide more specialized services. Smaller school districts can sometimes pool their resources. But if this solution necessitates transporting the students with mental disabilities out of their own school district to a central location, it runs the risk of robbing the other students, like my grandchildren, of an enriching experience that I wouldn’t want to see them lose.

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.”

I drive a 10-year-old pickup truck. The air conditioner no longer works – not a real problem here in Maine. It has hand-operated roll down windows ... a real plus should I back too far down the boat ramp and find myself in the cold waters of the Atlantic. If I ever decide to lock it, I will need to use a real key. But the pile of mismatched work gloves and rusty garden tools stashed behind the front seat hasn’t seemed to attract any burglars. Its dented body sits on a new frame, thanks to a generous recall from the manufacturer.

It’s a four-wheel drive, handy in the winter. But what I really like about it is that my old truck has a standard manual transmission. I still have that boyish enthusiasm for shifting gears. I can imagine myself driving a low-slung sports car or operating some gargantuan piece of heavy machinery.

Driving a stick shift vehicle demands a level of engagement and concentration several levels above that of simply aiming a car equipped with an automatic transmission. While I am sure some have tried, shifting gears is a serious deterrent to texting at the wheel.

The fact that our three children learned to drive on a standard shift station wagon is a tribute to their parents’ ability to tolerate repeated whiplash injuries. But it also may be one of the reasons that they survived those deadly middle teenage years. Nichole Morris, a researcher at the Human FIRST Laboratory of the University of Minnesota has said, “If you are going to have an early, untimely death, the most dangerous 2 years of your life are between 16 and 17, and the reason for that is driving” (“Teenage Drivers? Be Very Afraid,” by Bruce Feiler, New York Times, March 19, 2016). Six teenagers a day die from motor vehicle accident–related injuries, according to the Centers for Disease Control and Prevention. There are more deaths from motor vehicle accidents in this age group than from suicides, cancer, and other accidents.

©Thinkstock.com

An unfortunate combination of perceived invincibility and inexperience in an environment richly decorated with distractions makes those first years behind the wheel so dangerous. Charlie Klauer, a researcher at Virginia Tech’s Transportation Institute, believes that one in four teenagers will be involved in a motor vehicle crash in his or her first 6 months of driving. My personal experience supports her observation. Luckily, my daughter’s first accident was a low speed rear-ender into a giant pickup truck that sustained no obvious damage.

Given these frightening statistics, it is surprising that any parents would ever allow their teenage children to start on the path toward a driver’s license. As physicians committed to the health and safety of children, why haven’t pediatricians done more to prevent this tragic loss of life? The honest answer is simply that the motor vehicle is too tightly woven into our culture. We have tried, but we could probably do more.

Technological advances such as self-braking cars that are spinning off from the development of autonomous vehicles may save a few teenage drivers. But, watching your 17-year-old child take the wheel for the first time will continue to be an anxiety-provoking experience for the foreseeable future. We can help by reminding parents that the driving is a privilege that can easily be revoked. We must continue to urge parents to create and enforce rules about the use of cell phones behind the wheel. Many states have enacted laws that restrict teenage drivers from driving with other teens in the car, a well-known and often fatal distraction. But parents must be reminded that they are the first line of enforcement.

Enduring those neck-snapping sessions that are unavoidable when your child is learning to drive a standard shift vehicle was a sacrifice my wife and I made gladly. Manual transmissions aren’t coming back. But there are still plenty of sacrifices for today’s parents to make if they want their children to survive those deadly midteen years.

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.”

I drive a 10-year-old pickup truck. The air conditioner no longer works – not a real problem here in Maine. It has hand-operated roll down windows ... a real plus should I back too far down the boat ramp and find myself in the cold waters of the Atlantic. If I ever decide to lock it, I will need to use a real key. But the pile of mismatched work gloves and rusty garden tools stashed behind the front seat hasn’t seemed to attract any burglars. Its dented body sits on a new frame, thanks to a generous recall from the manufacturer.

It’s a four-wheel drive, handy in the winter. But what I really like about it is that my old truck has a standard manual transmission. I still have that boyish enthusiasm for shifting gears. I can imagine myself driving a low-slung sports car or operating some gargantuan piece of heavy machinery.

Driving a stick shift vehicle demands a level of engagement and concentration several levels above that of simply aiming a car equipped with an automatic transmission. While I am sure some have tried, shifting gears is a serious deterrent to texting at the wheel.

The fact that our three children learned to drive on a standard shift station wagon is a tribute to their parents’ ability to tolerate repeated whiplash injuries. But it also may be one of the reasons that they survived those deadly middle teenage years. Nichole Morris, a researcher at the Human FIRST Laboratory of the University of Minnesota has said, “If you are going to have an early, untimely death, the most dangerous 2 years of your life are between 16 and 17, and the reason for that is driving” (“Teenage Drivers? Be Very Afraid,” by Bruce Feiler, New York Times, March 19, 2016). Six teenagers a day die from motor vehicle accident–related injuries, according to the Centers for Disease Control and Prevention. There are more deaths from motor vehicle accidents in this age group than from suicides, cancer, and other accidents.

©Thinkstock.com

An unfortunate combination of perceived invincibility and inexperience in an environment richly decorated with distractions makes those first years behind the wheel so dangerous. Charlie Klauer, a researcher at Virginia Tech’s Transportation Institute, believes that one in four teenagers will be involved in a motor vehicle crash in his or her first 6 months of driving. My personal experience supports her observation. Luckily, my daughter’s first accident was a low speed rear-ender into a giant pickup truck that sustained no obvious damage.

Given these frightening statistics, it is surprising that any parents would ever allow their teenage children to start on the path toward a driver’s license. As physicians committed to the health and safety of children, why haven’t pediatricians done more to prevent this tragic loss of life? The honest answer is simply that the motor vehicle is too tightly woven into our culture. We have tried, but we could probably do more.

Technological advances such as self-braking cars that are spinning off from the development of autonomous vehicles may save a few teenage drivers. But, watching your 17-year-old child take the wheel for the first time will continue to be an anxiety-provoking experience for the foreseeable future. We can help by reminding parents that the driving is a privilege that can easily be revoked. We must continue to urge parents to create and enforce rules about the use of cell phones behind the wheel. Many states have enacted laws that restrict teenage drivers from driving with other teens in the car, a well-known and often fatal distraction. But parents must be reminded that they are the first line of enforcement.

Enduring those neck-snapping sessions that are unavoidable when your child is learning to drive a standard shift vehicle was a sacrifice my wife and I made gladly. Manual transmissions aren’t coming back. But there are still plenty of sacrifices for today’s parents to make if they want their children to survive those deadly midteen years.

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.”

I drive a 10-year-old pickup truck. The air conditioner no longer works – not a real problem here in Maine. It has hand-operated roll down windows ... a real plus should I back too far down the boat ramp and find myself in the cold waters of the Atlantic. If I ever decide to lock it, I will need to use a real key. But the pile of mismatched work gloves and rusty garden tools stashed behind the front seat hasn’t seemed to attract any burglars. Its dented body sits on a new frame, thanks to a generous recall from the manufacturer.

It’s a four-wheel drive, handy in the winter. But what I really like about it is that my old truck has a standard manual transmission. I still have that boyish enthusiasm for shifting gears. I can imagine myself driving a low-slung sports car or operating some gargantuan piece of heavy machinery.

Driving a stick shift vehicle demands a level of engagement and concentration several levels above that of simply aiming a car equipped with an automatic transmission. While I am sure some have tried, shifting gears is a serious deterrent to texting at the wheel.

The fact that our three children learned to drive on a standard shift station wagon is a tribute to their parents’ ability to tolerate repeated whiplash injuries. But it also may be one of the reasons that they survived those deadly middle teenage years. Nichole Morris, a researcher at the Human FIRST Laboratory of the University of Minnesota has said, “If you are going to have an early, untimely death, the most dangerous 2 years of your life are between 16 and 17, and the reason for that is driving” (“Teenage Drivers? Be Very Afraid,” by Bruce Feiler, New York Times, March 19, 2016). Six teenagers a day die from motor vehicle accident–related injuries, according to the Centers for Disease Control and Prevention. There are more deaths from motor vehicle accidents in this age group than from suicides, cancer, and other accidents.

©Thinkstock.com

An unfortunate combination of perceived invincibility and inexperience in an environment richly decorated with distractions makes those first years behind the wheel so dangerous. Charlie Klauer, a researcher at Virginia Tech’s Transportation Institute, believes that one in four teenagers will be involved in a motor vehicle crash in his or her first 6 months of driving. My personal experience supports her observation. Luckily, my daughter’s first accident was a low speed rear-ender into a giant pickup truck that sustained no obvious damage.

Given these frightening statistics, it is surprising that any parents would ever allow their teenage children to start on the path toward a driver’s license. As physicians committed to the health and safety of children, why haven’t pediatricians done more to prevent this tragic loss of life? The honest answer is simply that the motor vehicle is too tightly woven into our culture. We have tried, but we could probably do more.

Technological advances such as self-braking cars that are spinning off from the development of autonomous vehicles may save a few teenage drivers. But, watching your 17-year-old child take the wheel for the first time will continue to be an anxiety-provoking experience for the foreseeable future. We can help by reminding parents that the driving is a privilege that can easily be revoked. We must continue to urge parents to create and enforce rules about the use of cell phones behind the wheel. Many states have enacted laws that restrict teenage drivers from driving with other teens in the car, a well-known and often fatal distraction. But parents must be reminded that they are the first line of enforcement.

Enduring those neck-snapping sessions that are unavoidable when your child is learning to drive a standard shift vehicle was a sacrifice my wife and I made gladly. Manual transmissions aren’t coming back. But there are still plenty of sacrifices for today’s parents to make if they want their children to survive those deadly midteen years.

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.”

“Just say no to overprescribing!” It has such a straightforward Nancy Reagan-ish sound to it. But when it comes to drugs, whether it is crack cocaine or a prescription antibiotic, simple slogans don’t alter behavior.

While most physicians aren’t drug addicts, we do share something in common with other substance abusers. We are all human, and we are all influenced by the social contexts that we inhabit. The global health problems rippling out from the overuse of antibiotics are significant, unmistakable, and well documented. Certainly, we physicians must share some of the blame with the food industry for this unfortunate situation. There is some glimmer of hope that pressure from consumers has begun to convince a few food producers to be more judicious in their use of antibiotics.

However, there seems to be little or no pressure from patients on physicians to curtail our antibiotic prescribing habits. If physicians feel any pressure from patients, it is in the form of stated or more often unstated requests for antibiotics to treat conditions for which we know they are inappropriate. There is some question as to how often this perception of patient pressure actually occurs. It may be that the pressure physicians are feeling could be better described as fear – fear that the patient will die because of an undiscovered and untreated infection. Regardless of what motivates physicians to overprescribe antibiotics, the fact is that this kind of clinical misbehavior is difficult to change.

I recently read an article in which three medical school professors describe several behavior modification strategies that they have found to be effective in discouraging overprescribing (“How to Stop Overprescribing Antibiotics,” by Craig R. Fox, Jeffrey A. Linder, and Jason N. Doctor, New York Times, March 25, 2016). In one study, the researchers found that physicians who posted a pledge to follow antibiotic guidelines reduced inappropriate prescribing by 20%. In another study the investigators found that when physicians were presented with a list of medications in a format that presented the “more aggressive” drugs in a group, as opposed to singly in a vertical column, the physicians were 12% less likely to prescribe those medications.

Better results were achieved when physicians were provided with monthly reports of their prescribing habits in comparison with those of their peers. The physicians whose prescribing patterns followed accepted guidelines most closely were complimented as being “top performers.” Those physicians who did less well were told, “You are not a top performer.” This strategy nearly eliminated inappropriate prescribing. Similar improvement occurred when physicians who clicked their mouse on an antibiotic in a clinical scenario where it was not appropriate were given a screen prompt asking them to type in a short “antibiotic justification note.”

What all of these strategies have in common is that none of them uses financial gain as a motivator. Previous studies have shown that if financial rewards work, it is only for short periods of time. Instead, these strategies leverage our inherent competitive nature and take advantage of the fact that most of us want to do the right thing. We just need a little nudge every now and then. It is also encouraging to learn that none of these strategies incorporates a punishment.

I suspect that further studies will show that a screen prompt in the medical record requiring the overprescribing physician to justify his or her prescription will be the most effective in the long run. In my experience, physicians will do anything to shorten the amount of time they spend at their office computers.

At least two of these strategies hold the promise of being very powerful behavior modifiers. Those wielding these powerful tools must exercise that power carefully and be sure that evidence supporting their target behaviors is solid and continually updated. More importantly, those of us whose behavior is being modified should have a voice in the choice of which behaviors are to be modified.

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.”

“Just say no to overprescribing!” It has such a straightforward Nancy Reagan-ish sound to it. But when it comes to drugs, whether it is crack cocaine or a prescription antibiotic, simple slogans don’t alter behavior.

While most physicians aren’t drug addicts, we do share something in common with other substance abusers. We are all human, and we are all influenced by the social contexts that we inhabit. The global health problems rippling out from the overuse of antibiotics are significant, unmistakable, and well documented. Certainly, we physicians must share some of the blame with the food industry for this unfortunate situation. There is some glimmer of hope that pressure from consumers has begun to convince a few food producers to be more judicious in their use of antibiotics.

However, there seems to be little or no pressure from patients on physicians to curtail our antibiotic prescribing habits. If physicians feel any pressure from patients, it is in the form of stated or more often unstated requests for antibiotics to treat conditions for which we know they are inappropriate. There is some question as to how often this perception of patient pressure actually occurs. It may be that the pressure physicians are feeling could be better described as fear – fear that the patient will die because of an undiscovered and untreated infection. Regardless of what motivates physicians to overprescribe antibiotics, the fact is that this kind of clinical misbehavior is difficult to change.

I recently read an article in which three medical school professors describe several behavior modification strategies that they have found to be effective in discouraging overprescribing (“How to Stop Overprescribing Antibiotics,” by Craig R. Fox, Jeffrey A. Linder, and Jason N. Doctor, New York Times, March 25, 2016). In one study, the researchers found that physicians who posted a pledge to follow antibiotic guidelines reduced inappropriate prescribing by 20%. In another study the investigators found that when physicians were presented with a list of medications in a format that presented the “more aggressive” drugs in a group, as opposed to singly in a vertical column, the physicians were 12% less likely to prescribe those medications.

Better results were achieved when physicians were provided with monthly reports of their prescribing habits in comparison with those of their peers. The physicians whose prescribing patterns followed accepted guidelines most closely were complimented as being “top performers.” Those physicians who did less well were told, “You are not a top performer.” This strategy nearly eliminated inappropriate prescribing. Similar improvement occurred when physicians who clicked their mouse on an antibiotic in a clinical scenario where it was not appropriate were given a screen prompt asking them to type in a short “antibiotic justification note.”

What all of these strategies have in common is that none of them uses financial gain as a motivator. Previous studies have shown that if financial rewards work, it is only for short periods of time. Instead, these strategies leverage our inherent competitive nature and take advantage of the fact that most of us want to do the right thing. We just need a little nudge every now and then. It is also encouraging to learn that none of these strategies incorporates a punishment.

I suspect that further studies will show that a screen prompt in the medical record requiring the overprescribing physician to justify his or her prescription will be the most effective in the long run. In my experience, physicians will do anything to shorten the amount of time they spend at their office computers.

At least two of these strategies hold the promise of being very powerful behavior modifiers. Those wielding these powerful tools must exercise that power carefully and be sure that evidence supporting their target behaviors is solid and continually updated. More importantly, those of us whose behavior is being modified should have a voice in the choice of which behaviors are to be modified.

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.”

“Just say no to overprescribing!” It has such a straightforward Nancy Reagan-ish sound to it. But when it comes to drugs, whether it is crack cocaine or a prescription antibiotic, simple slogans don’t alter behavior.

While most physicians aren’t drug addicts, we do share something in common with other substance abusers. We are all human, and we are all influenced by the social contexts that we inhabit. The global health problems rippling out from the overuse of antibiotics are significant, unmistakable, and well documented. Certainly, we physicians must share some of the blame with the food industry for this unfortunate situation. There is some glimmer of hope that pressure from consumers has begun to convince a few food producers to be more judicious in their use of antibiotics.

However, there seems to be little or no pressure from patients on physicians to curtail our antibiotic prescribing habits. If physicians feel any pressure from patients, it is in the form of stated or more often unstated requests for antibiotics to treat conditions for which we know they are inappropriate. There is some question as to how often this perception of patient pressure actually occurs. It may be that the pressure physicians are feeling could be better described as fear – fear that the patient will die because of an undiscovered and untreated infection. Regardless of what motivates physicians to overprescribe antibiotics, the fact is that this kind of clinical misbehavior is difficult to change.

I recently read an article in which three medical school professors describe several behavior modification strategies that they have found to be effective in discouraging overprescribing (“How to Stop Overprescribing Antibiotics,” by Craig R. Fox, Jeffrey A. Linder, and Jason N. Doctor, New York Times, March 25, 2016). In one study, the researchers found that physicians who posted a pledge to follow antibiotic guidelines reduced inappropriate prescribing by 20%. In another study the investigators found that when physicians were presented with a list of medications in a format that presented the “more aggressive” drugs in a group, as opposed to singly in a vertical column, the physicians were 12% less likely to prescribe those medications.

Better results were achieved when physicians were provided with monthly reports of their prescribing habits in comparison with those of their peers. The physicians whose prescribing patterns followed accepted guidelines most closely were complimented as being “top performers.” Those physicians who did less well were told, “You are not a top performer.” This strategy nearly eliminated inappropriate prescribing. Similar improvement occurred when physicians who clicked their mouse on an antibiotic in a clinical scenario where it was not appropriate were given a screen prompt asking them to type in a short “antibiotic justification note.”

What all of these strategies have in common is that none of them uses financial gain as a motivator. Previous studies have shown that if financial rewards work, it is only for short periods of time. Instead, these strategies leverage our inherent competitive nature and take advantage of the fact that most of us want to do the right thing. We just need a little nudge every now and then. It is also encouraging to learn that none of these strategies incorporates a punishment.

I suspect that further studies will show that a screen prompt in the medical record requiring the overprescribing physician to justify his or her prescription will be the most effective in the long run. In my experience, physicians will do anything to shorten the amount of time they spend at their office computers.

At least two of these strategies hold the promise of being very powerful behavior modifiers. Those wielding these powerful tools must exercise that power carefully and be sure that evidence supporting their target behaviors is solid and continually updated. More importantly, those of us whose behavior is being modified should have a voice in the choice of which behaviors are to be modified.

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.”

Okay, let’s try this one more time. We agree that vaccine rates are declining and that the outbreak of measles believed to have spread from an index case at Disneyland is an example of the risk this country faces from those declining rates. In the last few years, there has been at least one study that found that providing vaccine-hesitant families with factual provaccine information failed to change parental attitudes. In fact, the educational effort backfired in some cases, and hesitant parents found other arguments to support their flawed positions. An equally discouraging study presented in the last year suggests that parents have already decided whether they will vaccinate even before they enter into childbearing, long before pediatricians have an opportunity to present their case.

In the face of this dismal landscape of antiscience, some pediatricians have decided to discharge vaccine-refusing families from their practices. Although this approach may create a thin shell of protection against some malpractice suits, and provide their youngest patients a shred of protection from waiting-room acquired infection, it has no effect on the larger problem facing this country.

A study from the University of Illinois published in the Proceedings of the National Academy of Sciences entitled, “Countering anti-vaccine attitudes” (PNAS 2015 Aug 18;112[33]:10321-4) suggests that we may have been too timid in choosing our strategies to combat the antivaccine epidemic. From a group of more than 800 individuals across a broad economic base, a smaller group of 315 was culled using several strategies to ensure that the participants were paying attention. They were then divided into three subgroups whose pretest vaccine attitudes did not differ.

One group was presented with materials that included photographs of ill children with rashes and a testimonial from the mother whose child had had measles. A second group was presented with articles exposing the myth of a relationship between autism and the measles-mumps-rubella vaccine. This group was labeled the “autism correction” group. The control group was presented with several scientific articles unrelated to vaccines.

The researchers found that while the control group and the autism correction group showed no change in their attitudes to vaccines, those individuals presented with graphic evidence of the risk of disease did demonstrate a significant change in attitude. So, the message would seem to be that scaring parents might work.

I’m not sure why pediatricians have been so hesitant to employ scare tactics in the past. While you and I may be more easily convinced by science-based evidence than the average parent, we also have seen children with vaccine-preventable diseases or at least seen pictures and heard their horrible histories. I suspect that our provaccine attitudes are colored more by the horrors that we have seen and heard than by our lip service to the sanctity of science.

We may have been too worried about being labeled as fear mongers if we showed graphic pictures of sick and dying children and promoted tear-jerking testimonials from parents. If we were a business whose bottom line depended on selling vaccines, our marketing and advertising folks would have sent us on the fear-generating pathway long ago.

It is time to ask ourselves if the situation is so dire that it is time to stop pussyfooting around with soft educational messages and begin trying to scare the vaccine deniers into protecting their children – and everyone else’s.

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.”

Okay, let’s try this one more time. We agree that vaccine rates are declining and that the outbreak of measles believed to have spread from an index case at Disneyland is an example of the risk this country faces from those declining rates. In the last few years, there has been at least one study that found that providing vaccine-hesitant families with factual provaccine information failed to change parental attitudes. In fact, the educational effort backfired in some cases, and hesitant parents found other arguments to support their flawed positions. An equally discouraging study presented in the last year suggests that parents have already decided whether they will vaccinate even before they enter into childbearing, long before pediatricians have an opportunity to present their case.

In the face of this dismal landscape of antiscience, some pediatricians have decided to discharge vaccine-refusing families from their practices. Although this approach may create a thin shell of protection against some malpractice suits, and provide their youngest patients a shred of protection from waiting-room acquired infection, it has no effect on the larger problem facing this country.

A study from the University of Illinois published in the Proceedings of the National Academy of Sciences entitled, “Countering anti-vaccine attitudes” (PNAS 2015 Aug 18;112[33]:10321-4) suggests that we may have been too timid in choosing our strategies to combat the antivaccine epidemic. From a group of more than 800 individuals across a broad economic base, a smaller group of 315 was culled using several strategies to ensure that the participants were paying attention. They were then divided into three subgroups whose pretest vaccine attitudes did not differ.

One group was presented with materials that included photographs of ill children with rashes and a testimonial from the mother whose child had had measles. A second group was presented with articles exposing the myth of a relationship between autism and the measles-mumps-rubella vaccine. This group was labeled the “autism correction” group. The control group was presented with several scientific articles unrelated to vaccines.

The researchers found that while the control group and the autism correction group showed no change in their attitudes to vaccines, those individuals presented with graphic evidence of the risk of disease did demonstrate a significant change in attitude. So, the message would seem to be that scaring parents might work.

I’m not sure why pediatricians have been so hesitant to employ scare tactics in the past. While you and I may be more easily convinced by science-based evidence than the average parent, we also have seen children with vaccine-preventable diseases or at least seen pictures and heard their horrible histories. I suspect that our provaccine attitudes are colored more by the horrors that we have seen and heard than by our lip service to the sanctity of science.

We may have been too worried about being labeled as fear mongers if we showed graphic pictures of sick and dying children and promoted tear-jerking testimonials from parents. If we were a business whose bottom line depended on selling vaccines, our marketing and advertising folks would have sent us on the fear-generating pathway long ago.

It is time to ask ourselves if the situation is so dire that it is time to stop pussyfooting around with soft educational messages and begin trying to scare the vaccine deniers into protecting their children – and everyone else’s.

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.”

Okay, let’s try this one more time. We agree that vaccine rates are declining and that the outbreak of measles believed to have spread from an index case at Disneyland is an example of the risk this country faces from those declining rates. In the last few years, there has been at least one study that found that providing vaccine-hesitant families with factual provaccine information failed to change parental attitudes. In fact, the educational effort backfired in some cases, and hesitant parents found other arguments to support their flawed positions. An equally discouraging study presented in the last year suggests that parents have already decided whether they will vaccinate even before they enter into childbearing, long before pediatricians have an opportunity to present their case.

In the face of this dismal landscape of antiscience, some pediatricians have decided to discharge vaccine-refusing families from their practices. Although this approach may create a thin shell of protection against some malpractice suits, and provide their youngest patients a shred of protection from waiting-room acquired infection, it has no effect on the larger problem facing this country.

A study from the University of Illinois published in the Proceedings of the National Academy of Sciences entitled, “Countering anti-vaccine attitudes” (PNAS 2015 Aug 18;112[33]:10321-4) suggests that we may have been too timid in choosing our strategies to combat the antivaccine epidemic. From a group of more than 800 individuals across a broad economic base, a smaller group of 315 was culled using several strategies to ensure that the participants were paying attention. They were then divided into three subgroups whose pretest vaccine attitudes did not differ.

One group was presented with materials that included photographs of ill children with rashes and a testimonial from the mother whose child had had measles. A second group was presented with articles exposing the myth of a relationship between autism and the measles-mumps-rubella vaccine. This group was labeled the “autism correction” group. The control group was presented with several scientific articles unrelated to vaccines.

The researchers found that while the control group and the autism correction group showed no change in their attitudes to vaccines, those individuals presented with graphic evidence of the risk of disease did demonstrate a significant change in attitude. So, the message would seem to be that scaring parents might work.

I’m not sure why pediatricians have been so hesitant to employ scare tactics in the past. While you and I may be more easily convinced by science-based evidence than the average parent, we also have seen children with vaccine-preventable diseases or at least seen pictures and heard their horrible histories. I suspect that our provaccine attitudes are colored more by the horrors that we have seen and heard than by our lip service to the sanctity of science.

We may have been too worried about being labeled as fear mongers if we showed graphic pictures of sick and dying children and promoted tear-jerking testimonials from parents. If we were a business whose bottom line depended on selling vaccines, our marketing and advertising folks would have sent us on the fear-generating pathway long ago.

It is time to ask ourselves if the situation is so dire that it is time to stop pussyfooting around with soft educational messages and begin trying to scare the vaccine deniers into protecting their children – and everyone else’s.

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 the early 1970’s, the three letters that a pediatric house officer hated to see on a slip returning from the lab were Q.N.S. Quality Not Sufficient meant that the minutes, which seemed like hours, you had invested torturing some poor sick child to obtain just a few cc’s of blood had been wasted. It also meant returning to the patient’s crib or bedside to explain to the child and her parents that the torture you had promised was over for the day was in fact not over.

Tourniquets were fished out of lapel buttonholes, and the search for a decent vein had to begin all over again. If the child was chubby or bloated with retained fluid, those veins were invisible. If the child had been ill for weeks – particularly if the patient had been on chemotherapy – all of the good veins had been blown or had clotted days ago.

Many of the patients were saintly and eerily cooperative despite your fumbling attempts at venipuncture, but most were not. Some parents were so supportive of your efforts that you wanted to hug them when the ordeal was over (and you did). A few parents amped up the tension at the bedside so much that you wanted to ask them to leave (but you didn’t). If a parent was understandably incapable of effectively restraining the child, you needed to find an experienced nurse to help. A few of the best nurses were so good that the house officer merely needed to hold the needle still, and the child was repositioned in just the right orientation so that the puncture occurred miraculously.

There were some last ditch efforts at phlebotomy that were so ghastly that you had to ask the parents to leave. I don’t know if the infamous internal jugular stick is still used, but it wasn’t pretty. And it was almost as frightening for the physician holding the needle as it was for the patient. Even in the big teaching hospitals, dedicated phlebotomists hadn’t been invented yet. A few nurses had earned reputations as good vein finders, but for the most part it was on-the-job training for the house officers.

It was not until 1973 that Dr. John Broviac’s central line catheters became available in some hospitals and 1979 until Dr. Robert Hickman’s version appeared. It took a few more years before techniques were perfected for safely drawing specimens from these lines that had been originally intended for infusion. But for me and my cohort of house officers and our unfortunate patients, it was years too late. I am sure that caring for hospitalized pediatric cancer patients today continues to be dominated by challenges. But for those of us tasked with drawing blood from patients without the benefit of central line catheters, it was gut wrenching.

Those battles for a few cc’s of blood left their scars. I have seldom ordered any blood test without asking myself whether there wasn’t a bloodless way of assessing the patient’s condition. Or couldn’t we just do the test on a drop or two of blood? Of course, as I as finishing my training, more tests were downsized so that they could be done “micro.” But as you know, getting enough blood from a heel stick or finger prick isn’t always as easy as it sounds. If the child is shocky or cold, a good blood flow is hard to obtain. Warming helps but squeezing doesn’t because tissue juices can dilute the sample, and the trauma of squeezing can contaminate the sample.

A study published in the American Journal of Clinical Pathology raises the question of how accurately even a single drop of blood reflects what is going on in the patient’s total blood pool (“Drop by drop variation in the cellular components of fingerprick blood: Implications for point-of-care diagnostic development” [Am J Clin Pathol. 2015 Dec;144(6):885-94]). Two bioengineers from Rice University discovered that six successive drops of blood from a single finger prick varied by a significant amount when analyzed for a variety of cellular components. For example, the drop-to-drop variability for hemoglobin was five times that of a sample collected by venipuncture.

You and I may dream of the day when just a drop will do it and we can put our needles away for good. Unfortunately, for now, the answer is that a single drop of blood is a Q.N.S.

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 the early 1970’s, the three letters that a pediatric house officer hated to see on a slip returning from the lab were Q.N.S. Quality Not Sufficient meant that the minutes, which seemed like hours, you had invested torturing some poor sick child to obtain just a few cc’s of blood had been wasted. It also meant returning to the patient’s crib or bedside to explain to the child and her parents that the torture you had promised was over for the day was in fact not over.

Tourniquets were fished out of lapel buttonholes, and the search for a decent vein had to begin all over again. If the child was chubby or bloated with retained fluid, those veins were invisible. If the child had been ill for weeks – particularly if the patient had been on chemotherapy – all of the good veins had been blown or had clotted days ago.

Many of the patients were saintly and eerily cooperative despite your fumbling attempts at venipuncture, but most were not. Some parents were so supportive of your efforts that you wanted to hug them when the ordeal was over (and you did). A few parents amped up the tension at the bedside so much that you wanted to ask them to leave (but you didn’t). If a parent was understandably incapable of effectively restraining the child, you needed to find an experienced nurse to help. A few of the best nurses were so good that the house officer merely needed to hold the needle still, and the child was repositioned in just the right orientation so that the puncture occurred miraculously.

There were some last ditch efforts at phlebotomy that were so ghastly that you had to ask the parents to leave. I don’t know if the infamous internal jugular stick is still used, but it wasn’t pretty. And it was almost as frightening for the physician holding the needle as it was for the patient. Even in the big teaching hospitals, dedicated phlebotomists hadn’t been invented yet. A few nurses had earned reputations as good vein finders, but for the most part it was on-the-job training for the house officers.

It was not until 1973 that Dr. John Broviac’s central line catheters became available in some hospitals and 1979 until Dr. Robert Hickman’s version appeared. It took a few more years before techniques were perfected for safely drawing specimens from these lines that had been originally intended for infusion. But for me and my cohort of house officers and our unfortunate patients, it was years too late. I am sure that caring for hospitalized pediatric cancer patients today continues to be dominated by challenges. But for those of us tasked with drawing blood from patients without the benefit of central line catheters, it was gut wrenching.

Those battles for a few cc’s of blood left their scars. I have seldom ordered any blood test without asking myself whether there wasn’t a bloodless way of assessing the patient’s condition. Or couldn’t we just do the test on a drop or two of blood? Of course, as I as finishing my training, more tests were downsized so that they could be done “micro.” But as you know, getting enough blood from a heel stick or finger prick isn’t always as easy as it sounds. If the child is shocky or cold, a good blood flow is hard to obtain. Warming helps but squeezing doesn’t because tissue juices can dilute the sample, and the trauma of squeezing can contaminate the sample.

A study published in the American Journal of Clinical Pathology raises the question of how accurately even a single drop of blood reflects what is going on in the patient’s total blood pool (“Drop by drop variation in the cellular components of fingerprick blood: Implications for point-of-care diagnostic development” [Am J Clin Pathol. 2015 Dec;144(6):885-94]). Two bioengineers from Rice University discovered that six successive drops of blood from a single finger prick varied by a significant amount when analyzed for a variety of cellular components. For example, the drop-to-drop variability for hemoglobin was five times that of a sample collected by venipuncture.

You and I may dream of the day when just a drop will do it and we can put our needles away for good. Unfortunately, for now, the answer is that a single drop of blood is a Q.N.S.

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 the early 1970’s, the three letters that a pediatric house officer hated to see on a slip returning from the lab were Q.N.S. Quality Not Sufficient meant that the minutes, which seemed like hours, you had invested torturing some poor sick child to obtain just a few cc’s of blood had been wasted. It also meant returning to the patient’s crib or bedside to explain to the child and her parents that the torture you had promised was over for the day was in fact not over.

Tourniquets were fished out of lapel buttonholes, and the search for a decent vein had to begin all over again. If the child was chubby or bloated with retained fluid, those veins were invisible. If the child had been ill for weeks – particularly if the patient had been on chemotherapy – all of the good veins had been blown or had clotted days ago.

Many of the patients were saintly and eerily cooperative despite your fumbling attempts at venipuncture, but most were not. Some parents were so supportive of your efforts that you wanted to hug them when the ordeal was over (and you did). A few parents amped up the tension at the bedside so much that you wanted to ask them to leave (but you didn’t). If a parent was understandably incapable of effectively restraining the child, you needed to find an experienced nurse to help. A few of the best nurses were so good that the house officer merely needed to hold the needle still, and the child was repositioned in just the right orientation so that the puncture occurred miraculously.

There were some last ditch efforts at phlebotomy that were so ghastly that you had to ask the parents to leave. I don’t know if the infamous internal jugular stick is still used, but it wasn’t pretty. And it was almost as frightening for the physician holding the needle as it was for the patient. Even in the big teaching hospitals, dedicated phlebotomists hadn’t been invented yet. A few nurses had earned reputations as good vein finders, but for the most part it was on-the-job training for the house officers.

It was not until 1973 that Dr. John Broviac’s central line catheters became available in some hospitals and 1979 until Dr. Robert Hickman’s version appeared. It took a few more years before techniques were perfected for safely drawing specimens from these lines that had been originally intended for infusion. But for me and my cohort of house officers and our unfortunate patients, it was years too late. I am sure that caring for hospitalized pediatric cancer patients today continues to be dominated by challenges. But for those of us tasked with drawing blood from patients without the benefit of central line catheters, it was gut wrenching.

Those battles for a few cc’s of blood left their scars. I have seldom ordered any blood test without asking myself whether there wasn’t a bloodless way of assessing the patient’s condition. Or couldn’t we just do the test on a drop or two of blood? Of course, as I as finishing my training, more tests were downsized so that they could be done “micro.” But as you know, getting enough blood from a heel stick or finger prick isn’t always as easy as it sounds. If the child is shocky or cold, a good blood flow is hard to obtain. Warming helps but squeezing doesn’t because tissue juices can dilute the sample, and the trauma of squeezing can contaminate the sample.

A study published in the American Journal of Clinical Pathology raises the question of how accurately even a single drop of blood reflects what is going on in the patient’s total blood pool (“Drop by drop variation in the cellular components of fingerprick blood: Implications for point-of-care diagnostic development” [Am J Clin Pathol. 2015 Dec;144(6):885-94]). Two bioengineers from Rice University discovered that six successive drops of blood from a single finger prick varied by a significant amount when analyzed for a variety of cellular components. For example, the drop-to-drop variability for hemoglobin was five times that of a sample collected by venipuncture.

You and I may dream of the day when just a drop will do it and we can put our needles away for good. Unfortunately, for now, the answer is that a single drop of blood is a Q.N.S.

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.”

It has been clear for a long time that a child who grows up in an environment dominated by adversity is more likely to enter adulthood scarred psychologically, and as a result is less likely to succeed. This well-described association has in the last few years become a hot button topic. A 2012 American Academy of Pediatrics policy statement alerted pediatricians to their potential role in identifying and managing what is now referred to as “toxic stress” (“Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health”).

Although a childhood in which challenges outnumber advantages is often followed by an adult life characterized by failure and dysfunction, there are a few individuals who not only survive a disadvantaged childhood unscathed but somehow manage to thrive in its wake. For example, Joe Rantz, the central figure in Daniel James Brown’s nonfiction best seller “The Boys in the Boat” (New York: Viking Press, 2013) was abandoned several times by his family but emerged to power the University of Washington crew team to victory in the 1936 Olympics. Intrigued by these outliers, a developmental psychologist and clinician from the University of Minnesota named Norman Garmezy began looking for features that may have allowed these exceptional people to succeed and even excel despite incredibly difficult circumstances (“How People Learn to Become Resilient,” Maria Konnikova, The New Yorker, Feb. 11, 2016). His search for the characteristics that might have protected these individuals as children from the acute and chronic environmental threats of their disadvantaged childhoods has spawned a breed of developmental psychologists who devote their research to a quality now referred to as “resilience.”

In 1989, Emmy E. Werner, Ph.D., published a study of 698 children on the island of Kauai in Hawaii and identified several elements that might predict resilience (“Children of the Garden Island,” Sci Am. 1989;260[4]:106-11). Not surprisingly, one factor was the good luck of having formed a strong bond with a supportive person such as a caregiver or mentor. However, Dr. Werner also discovered that resilient individuals possessed a set of psychological characteristics that included a positive social orientation prompting them to “meet the world on their own terms.” They were likely to be autonomous and independent and had the attitude that “they, and not their circumstances, affected their achievements.”

These findings lead to the obvious question of whether those attributes that can protect against adversity can be taught. George Bonanno, a clinical psychologist at Columbia University’s Teachers College, found that an individual’s perception of the situation is the key element in resilience. In the New Yorker article on resilience, he was quoted in an interview as saying, “Events are not traumatic until we experience them as traumatic.” In his studies he has found that individuals can be taught how to reframe an event in positive terms that was initially perceived as negative. Unfortunately, the reverse can occur, and as Dr. Bonanno also said in the interview, “We can create or exaggerate stressors very easily in our own minds.” Every event is potentially traumatic if we perceive it that way.

Could it be that in some situations our behavior as adults, parents, and professionals creates an environment that transforms an event into one that is more easily perceived by a child as traumatizing? While it is important to be on the lookout for children who have been emotionally traumatized by an unfortunate event such as a school shooting, we must be careful to keep our responses measured and positive. Children should be reminded that it is they who control their own behavior and achievements, not the circumstances in which they find themselves.

Parents should be reminded that hovering and overinvolvement in their children’s lives is preventing the development of independence and a sense of autonomy, two important characteristics of resilience. The trend in education that emphasizes group solutions may be helping some children learn to cooperate with others and function as a team. But, we must also remember to offer each individual child abundant opportunities to learn so that he or she can also rely on himself or herself to solve problems.

Few of us will ever have the capacity for resiliency demonstrated by Louis Zamperini in the nonfiction best seller Unbroken, but we can and should be doing a better job helping children learn that even in the most adverse conditions, they have some control – if not over the circumstance, then at least over their perception of it.

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.”

It has been clear for a long time that a child who grows up in an environment dominated by adversity is more likely to enter adulthood scarred psychologically, and as a result is less likely to succeed. This well-described association has in the last few years become a hot button topic. A 2012 American Academy of Pediatrics policy statement alerted pediatricians to their potential role in identifying and managing what is now referred to as “toxic stress” (“Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health”).

Although a childhood in which challenges outnumber advantages is often followed by an adult life characterized by failure and dysfunction, there are a few individuals who not only survive a disadvantaged childhood unscathed but somehow manage to thrive in its wake. For example, Joe Rantz, the central figure in Daniel James Brown’s nonfiction best seller “The Boys in the Boat” (New York: Viking Press, 2013) was abandoned several times by his family but emerged to power the University of Washington crew team to victory in the 1936 Olympics. Intrigued by these outliers, a developmental psychologist and clinician from the University of Minnesota named Norman Garmezy began looking for features that may have allowed these exceptional people to succeed and even excel despite incredibly difficult circumstances (“How People Learn to Become Resilient,” Maria Konnikova, The New Yorker, Feb. 11, 2016). His search for the characteristics that might have protected these individuals as children from the acute and chronic environmental threats of their disadvantaged childhoods has spawned a breed of developmental psychologists who devote their research to a quality now referred to as “resilience.”

In 1989, Emmy E. Werner, Ph.D., published a study of 698 children on the island of Kauai in Hawaii and identified several elements that might predict resilience (“Children of the Garden Island,” Sci Am. 1989;260[4]:106-11). Not surprisingly, one factor was the good luck of having formed a strong bond with a supportive person such as a caregiver or mentor. However, Dr. Werner also discovered that resilient individuals possessed a set of psychological characteristics that included a positive social orientation prompting them to “meet the world on their own terms.” They were likely to be autonomous and independent and had the attitude that “they, and not their circumstances, affected their achievements.”

These findings lead to the obvious question of whether those attributes that can protect against adversity can be taught. George Bonanno, a clinical psychologist at Columbia University’s Teachers College, found that an individual’s perception of the situation is the key element in resilience. In the New Yorker article on resilience, he was quoted in an interview as saying, “Events are not traumatic until we experience them as traumatic.” In his studies he has found that individuals can be taught how to reframe an event in positive terms that was initially perceived as negative. Unfortunately, the reverse can occur, and as Dr. Bonanno also said in the interview, “We can create or exaggerate stressors very easily in our own minds.” Every event is potentially traumatic if we perceive it that way.

Could it be that in some situations our behavior as adults, parents, and professionals creates an environment that transforms an event into one that is more easily perceived by a child as traumatizing? While it is important to be on the lookout for children who have been emotionally traumatized by an unfortunate event such as a school shooting, we must be careful to keep our responses measured and positive. Children should be reminded that it is they who control their own behavior and achievements, not the circumstances in which they find themselves.

Parents should be reminded that hovering and overinvolvement in their children’s lives is preventing the development of independence and a sense of autonomy, two important characteristics of resilience. The trend in education that emphasizes group solutions may be helping some children learn to cooperate with others and function as a team. But, we must also remember to offer each individual child abundant opportunities to learn so that he or she can also rely on himself or herself to solve problems.

Few of us will ever have the capacity for resiliency demonstrated by Louis Zamperini in the nonfiction best seller Unbroken, but we can and should be doing a better job helping children learn that even in the most adverse conditions, they have some control – if not over the circumstance, then at least over their perception of it.

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.”

It has been clear for a long time that a child who grows up in an environment dominated by adversity is more likely to enter adulthood scarred psychologically, and as a result is less likely to succeed. This well-described association has in the last few years become a hot button topic. A 2012 American Academy of Pediatrics policy statement alerted pediatricians to their potential role in identifying and managing what is now referred to as “toxic stress” (“Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health”).

Although a childhood in which challenges outnumber advantages is often followed by an adult life characterized by failure and dysfunction, there are a few individuals who not only survive a disadvantaged childhood unscathed but somehow manage to thrive in its wake. For example, Joe Rantz, the central figure in Daniel James Brown’s nonfiction best seller “The Boys in the Boat” (New York: Viking Press, 2013) was abandoned several times by his family but emerged to power the University of Washington crew team to victory in the 1936 Olympics. Intrigued by these outliers, a developmental psychologist and clinician from the University of Minnesota named Norman Garmezy began looking for features that may have allowed these exceptional people to succeed and even excel despite incredibly difficult circumstances (“How People Learn to Become Resilient,” Maria Konnikova, The New Yorker, Feb. 11, 2016). His search for the characteristics that might have protected these individuals as children from the acute and chronic environmental threats of their disadvantaged childhoods has spawned a breed of developmental psychologists who devote their research to a quality now referred to as “resilience.”

In 1989, Emmy E. Werner, Ph.D., published a study of 698 children on the island of Kauai in Hawaii and identified several elements that might predict resilience (“Children of the Garden Island,” Sci Am. 1989;260[4]:106-11). Not surprisingly, one factor was the good luck of having formed a strong bond with a supportive person such as a caregiver or mentor. However, Dr. Werner also discovered that resilient individuals possessed a set of psychological characteristics that included a positive social orientation prompting them to “meet the world on their own terms.” They were likely to be autonomous and independent and had the attitude that “they, and not their circumstances, affected their achievements.”

These findings lead to the obvious question of whether those attributes that can protect against adversity can be taught. George Bonanno, a clinical psychologist at Columbia University’s Teachers College, found that an individual’s perception of the situation is the key element in resilience. In the New Yorker article on resilience, he was quoted in an interview as saying, “Events are not traumatic until we experience them as traumatic.” In his studies he has found that individuals can be taught how to reframe an event in positive terms that was initially perceived as negative. Unfortunately, the reverse can occur, and as Dr. Bonanno also said in the interview, “We can create or exaggerate stressors very easily in our own minds.” Every event is potentially traumatic if we perceive it that way.

Could it be that in some situations our behavior as adults, parents, and professionals creates an environment that transforms an event into one that is more easily perceived by a child as traumatizing? While it is important to be on the lookout for children who have been emotionally traumatized by an unfortunate event such as a school shooting, we must be careful to keep our responses measured and positive. Children should be reminded that it is they who control their own behavior and achievements, not the circumstances in which they find themselves.

Parents should be reminded that hovering and overinvolvement in their children’s lives is preventing the development of independence and a sense of autonomy, two important characteristics of resilience. The trend in education that emphasizes group solutions may be helping some children learn to cooperate with others and function as a team. But, we must also remember to offer each individual child abundant opportunities to learn so that he or she can also rely on himself or herself to solve problems.

Few of us will ever have the capacity for resiliency demonstrated by Louis Zamperini in the nonfiction best seller Unbroken, but we can and should be doing a better job helping children learn that even in the most adverse conditions, they have some control – if not over the circumstance, then at least over their perception of it.

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.”

How do you feel about hunger? Do you trust in its power? Having written one book on picky eating based solely on my mother’s wisdom, supplemented with a scanty amount of Internet-based research, I have spent and continue to spend a good bit of time thinking about hunger.

I have concluded that it is a very powerful force and that when a child gets hungry enough, he will eat, even foods that he has previously rejected. It is that assumption that is at the core of my advice to parents of picky eaters. I suspect that many of you share that same philosophy and recommend a strategy that is heavy on patience. Of course the problem lies in getting parents to adopt that attitude and accept the fact that if they just present a healthy diet and step back, hunger will eventually win, and the child will eat.

However, the devil is in the details. Have the parents set rules that will prevent the child from overdrinking? Have they really stopped talking about what the child, and everyone else in the family, is or isn’t eating? Are the parents setting good examples with their own eating habits and comments about food?

Because 99% of my patient population have been healthy, I have always felt comfortable relying on the power of hunger to win the battle over picky eating. If properly managed, none of my patients was going to die or suffer permanent consequences from picky eating. However, I have always wondered whether hunger could be leveraged to safely manage selective eating in children with serious health problems. I have a suspicion that it would succeed, but luckily I have never been presented with a case to test my hunch.

I recently read a very personal account written by the mother of a child with severe congenital cardiac disease that supports my gut feeling that when carefully monitored, starvation can be an effective strategy in managing selective eating (“When Your Baby Won’t Eat,” by Virginia Sole-Smith, The New York Times Magazine, Feb. 4, 2016). Three surgeries in the first few months of life necessitated that the child be fed by gavage. Attempts at breastfeeding failed, as it often does in situations like this. Struggles with gavage tube placement at home became such an emotionally traumatic ordeal that eventually a gastrostomy tube was placed when the child was 6 months old.

The family was led to believe that an important window in the child’s oral development had closed as a result of interventions necessitated by the child’s cardiac malformations. Although she was neurologically and physically capable of eating, getting her to do so was going to require long-term behavior modification, and there was no guarantee that this approach would completely undo what bad luck and prior management strategies had created. She might never relate to food as a normal child does.

After several attempts at behavior management using one-to-one reinforcement, this mother began to do some research. She discovered that of the nearly 30 feeding programs in children’s hospitals and private clinics, almost all use variations of a similar behavior modification strategy that had not worked for her daughter. As she observed: “This behavioral model presumes that children who don’t eat need external motivation.”

Eventually, the family found help in one of the few feeding programs in the United States that has adopted a dramatically different “child-centered” approach in which “therapists believe that all children have some internal motivation to eat, as well as an innate ability to effectively self-regulate their intake.” The solution to this child’s problem didn’t occur overnight. It began by exposing the child to a variety of foods in situations free of attempts to get her to eat – no coercion or rewards, regardless of how subtle they might have seemed. Once the child was experimenting with food, her tube feedings were gradually decreased in volume and caloric content. And, voila! Hunger won and the child began meeting her total nutritional needs by eating, in some cases with gusto.

Of course I was easy to convince because the results confirmed my hunch. But, do you believe that hunger can and should be used as the centerpiece in the management of selective eating, even in cases well beyond the parameters of garden variety picky eating? Are you willing to play the hunger game along with me?

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.”

How do you feel about hunger? Do you trust in its power? Having written one book on picky eating based solely on my mother’s wisdom, supplemented with a scanty amount of Internet-based research, I have spent and continue to spend a good bit of time thinking about hunger.

I have concluded that it is a very powerful force and that when a child gets hungry enough, he will eat, even foods that he has previously rejected. It is that assumption that is at the core of my advice to parents of picky eaters. I suspect that many of you share that same philosophy and recommend a strategy that is heavy on patience. Of course the problem lies in getting parents to adopt that attitude and accept the fact that if they just present a healthy diet and step back, hunger will eventually win, and the child will eat.

However, the devil is in the details. Have the parents set rules that will prevent the child from overdrinking? Have they really stopped talking about what the child, and everyone else in the family, is or isn’t eating? Are the parents setting good examples with their own eating habits and comments about food?

Because 99% of my patient population have been healthy, I have always felt comfortable relying on the power of hunger to win the battle over picky eating. If properly managed, none of my patients was going to die or suffer permanent consequences from picky eating. However, I have always wondered whether hunger could be leveraged to safely manage selective eating in children with serious health problems. I have a suspicion that it would succeed, but luckily I have never been presented with a case to test my hunch.

I recently read a very personal account written by the mother of a child with severe congenital cardiac disease that supports my gut feeling that when carefully monitored, starvation can be an effective strategy in managing selective eating (“When Your Baby Won’t Eat,” by Virginia Sole-Smith, The New York Times Magazine, Feb. 4, 2016). Three surgeries in the first few months of life necessitated that the child be fed by gavage. Attempts at breastfeeding failed, as it often does in situations like this. Struggles with gavage tube placement at home became such an emotionally traumatic ordeal that eventually a gastrostomy tube was placed when the child was 6 months old.

The family was led to believe that an important window in the child’s oral development had closed as a result of interventions necessitated by the child’s cardiac malformations. Although she was neurologically and physically capable of eating, getting her to do so was going to require long-term behavior modification, and there was no guarantee that this approach would completely undo what bad luck and prior management strategies had created. She might never relate to food as a normal child does.

After several attempts at behavior management using one-to-one reinforcement, this mother began to do some research. She discovered that of the nearly 30 feeding programs in children’s hospitals and private clinics, almost all use variations of a similar behavior modification strategy that had not worked for her daughter. As she observed: “This behavioral model presumes that children who don’t eat need external motivation.”

Eventually, the family found help in one of the few feeding programs in the United States that has adopted a dramatically different “child-centered” approach in which “therapists believe that all children have some internal motivation to eat, as well as an innate ability to effectively self-regulate their intake.” The solution to this child’s problem didn’t occur overnight. It began by exposing the child to a variety of foods in situations free of attempts to get her to eat – no coercion or rewards, regardless of how subtle they might have seemed. Once the child was experimenting with food, her tube feedings were gradually decreased in volume and caloric content. And, voila! Hunger won and the child began meeting her total nutritional needs by eating, in some cases with gusto.

Of course I was easy to convince because the results confirmed my hunch. But, do you believe that hunger can and should be used as the centerpiece in the management of selective eating, even in cases well beyond the parameters of garden variety picky eating? Are you willing to play the hunger game along with me?

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.”

How do you feel about hunger? Do you trust in its power? Having written one book on picky eating based solely on my mother’s wisdom, supplemented with a scanty amount of Internet-based research, I have spent and continue to spend a good bit of time thinking about hunger.

I have concluded that it is a very powerful force and that when a child gets hungry enough, he will eat, even foods that he has previously rejected. It is that assumption that is at the core of my advice to parents of picky eaters. I suspect that many of you share that same philosophy and recommend a strategy that is heavy on patience. Of course the problem lies in getting parents to adopt that attitude and accept the fact that if they just present a healthy diet and step back, hunger will eventually win, and the child will eat.

However, the devil is in the details. Have the parents set rules that will prevent the child from overdrinking? Have they really stopped talking about what the child, and everyone else in the family, is or isn’t eating? Are the parents setting good examples with their own eating habits and comments about food?

Because 99% of my patient population have been healthy, I have always felt comfortable relying on the power of hunger to win the battle over picky eating. If properly managed, none of my patients was going to die or suffer permanent consequences from picky eating. However, I have always wondered whether hunger could be leveraged to safely manage selective eating in children with serious health problems. I have a suspicion that it would succeed, but luckily I have never been presented with a case to test my hunch.

I recently read a very personal account written by the mother of a child with severe congenital cardiac disease that supports my gut feeling that when carefully monitored, starvation can be an effective strategy in managing selective eating (“When Your Baby Won’t Eat,” by Virginia Sole-Smith, The New York Times Magazine, Feb. 4, 2016). Three surgeries in the first few months of life necessitated that the child be fed by gavage. Attempts at breastfeeding failed, as it often does in situations like this. Struggles with gavage tube placement at home became such an emotionally traumatic ordeal that eventually a gastrostomy tube was placed when the child was 6 months old.

The family was led to believe that an important window in the child’s oral development had closed as a result of interventions necessitated by the child’s cardiac malformations. Although she was neurologically and physically capable of eating, getting her to do so was going to require long-term behavior modification, and there was no guarantee that this approach would completely undo what bad luck and prior management strategies had created. She might never relate to food as a normal child does.

After several attempts at behavior management using one-to-one reinforcement, this mother began to do some research. She discovered that of the nearly 30 feeding programs in children’s hospitals and private clinics, almost all use variations of a similar behavior modification strategy that had not worked for her daughter. As she observed: “This behavioral model presumes that children who don’t eat need external motivation.”

Eventually, the family found help in one of the few feeding programs in the United States that has adopted a dramatically different “child-centered” approach in which “therapists believe that all children have some internal motivation to eat, as well as an innate ability to effectively self-regulate their intake.” The solution to this child’s problem didn’t occur overnight. It began by exposing the child to a variety of foods in situations free of attempts to get her to eat – no coercion or rewards, regardless of how subtle they might have seemed. Once the child was experimenting with food, her tube feedings were gradually decreased in volume and caloric content. And, voila! Hunger won and the child began meeting her total nutritional needs by eating, in some cases with gusto.

Of course I was easy to convince because the results confirmed my hunch. But, do you believe that hunger can and should be used as the centerpiece in the management of selective eating, even in cases well beyond the parameters of garden variety picky eating? Are you willing to play the hunger game along with me?

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.”

I hope I am correct, but it seems to me that the “holistic” label is fading into the sunset. I never quite got what a holistic physician was doing that I wasn’t. Was I ignoring the fact that my patient came from a certain ethnic group and that his family had a particular set of religious beliefs? I may not have understood or agreed with those customs or beliefs. But I knew that I had better take them into account as I tried to find what was troubling the patient and help him search for a solution.

When the patient with frequent abdominal pains asked me for advice, did I fail to ask a social history because I didn’t think that the fact that her father had just lost his job or that her favorite grandmother was dying of cancer was important? Did I simply write prescriptions and avoid making recommendations about bedtimes, diet, exercise, and relaxation strategies? Did I stop my exam at the clavicles when the patient’s chief complaint was headache?

I’m sure that most physicians who marketed themselves as being holistic passionately believed that a good doctor must consider the whole patient. But what troubled me was the implication that the rest of us didn’t. I suspect that the fading popularity of the label reflects that patients began to realize that it was meaningless.

However, another buzzword has begun to flutter across the medical landscape. Every few days I open a magazine or journal in which someone is suggesting that I need to be more mindful. And they are more than willing to show me or sell me a technique for achieving mindfulness.

Is this just another packaging ploy, or should I begin paddling out to catch this new wave? The more I began to see mindfulness offered and promoted in a wider variety of settings, the more confused I became. So I did what anyone with a WiFi connection would do. I Googled “mindfulness” and discovered that I had good reason to feel confused.

It turns out that in some form or another mindfulness has been a practice in the Buddhist tradition with a history dating back hundreds of years. The first definition I found in Wikipedia read: “being aware moment-to-moment of one’s subjective conscious experience from a first-person perspective.” However, as I read further I discovered a reference to no fewer than 13 disparate definitions across a spectrum from attention and awareness on one end to retention and remindfulness on the other.

Some advocates feel that meditation should be used to prepare oneself to be mindful or that meditation is integral to mindfulness. Other folks don’t seem to see meditation as particularly necessary.

There is a growing body of literature reporting that something labeled mindfulness has helped patients and practitioners improve one or more aspects of wellness. Although the quality of these reports varies widely, it suggests along with the long Buddhist tradition that there is something out there called mindfulness worth investigating.

However, I wonder why it is becoming so widely ballyhooed. It seems to me that at its core, being mindful is simply just trying to do a better job of paying attention to the world around us and our fellow inhabitants. Is it simply the flip side of an attention deficiency? Or, is it an attempt to give a more exotic and mysterious Asian-influenced label to cognitive-behavioral therapy? Could it just be a less judgmental way of asking ourselves, “What were (are) you thinking?”

“Mindfulness” appears to have considerably more substance than “holistic,” but I fear that its indiscriminant use is going to damage its credibility. The overexposure has certainly triggered my skepticism.

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.”

I hope I am correct, but it seems to me that the “holistic” label is fading into the sunset. I never quite got what a holistic physician was doing that I wasn’t. Was I ignoring the fact that my patient came from a certain ethnic group and that his family had a particular set of religious beliefs? I may not have understood or agreed with those customs or beliefs. But I knew that I had better take them into account as I tried to find what was troubling the patient and help him search for a solution.

When the patient with frequent abdominal pains asked me for advice, did I fail to ask a social history because I didn’t think that the fact that her father had just lost his job or that her favorite grandmother was dying of cancer was important? Did I simply write prescriptions and avoid making recommendations about bedtimes, diet, exercise, and relaxation strategies? Did I stop my exam at the clavicles when the patient’s chief complaint was headache?

I’m sure that most physicians who marketed themselves as being holistic passionately believed that a good doctor must consider the whole patient. But what troubled me was the implication that the rest of us didn’t. I suspect that the fading popularity of the label reflects that patients began to realize that it was meaningless.

However, another buzzword has begun to flutter across the medical landscape. Every few days I open a magazine or journal in which someone is suggesting that I need to be more mindful. And they are more than willing to show me or sell me a technique for achieving mindfulness.

Is this just another packaging ploy, or should I begin paddling out to catch this new wave? The more I began to see mindfulness offered and promoted in a wider variety of settings, the more confused I became. So I did what anyone with a WiFi connection would do. I Googled “mindfulness” and discovered that I had good reason to feel confused.

It turns out that in some form or another mindfulness has been a practice in the Buddhist tradition with a history dating back hundreds of years. The first definition I found in Wikipedia read: “being aware moment-to-moment of one’s subjective conscious experience from a first-person perspective.” However, as I read further I discovered a reference to no fewer than 13 disparate definitions across a spectrum from attention and awareness on one end to retention and remindfulness on the other.

Some advocates feel that meditation should be used to prepare oneself to be mindful or that meditation is integral to mindfulness. Other folks don’t seem to see meditation as particularly necessary.

There is a growing body of literature reporting that something labeled mindfulness has helped patients and practitioners improve one or more aspects of wellness. Although the quality of these reports varies widely, it suggests along with the long Buddhist tradition that there is something out there called mindfulness worth investigating.

However, I wonder why it is becoming so widely ballyhooed. It seems to me that at its core, being mindful is simply just trying to do a better job of paying attention to the world around us and our fellow inhabitants. Is it simply the flip side of an attention deficiency? Or, is it an attempt to give a more exotic and mysterious Asian-influenced label to cognitive-behavioral therapy? Could it just be a less judgmental way of asking ourselves, “What were (are) you thinking?”

“Mindfulness” appears to have considerably more substance than “holistic,” but I fear that its indiscriminant use is going to damage its credibility. The overexposure has certainly triggered my skepticism.

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.”

I hope I am correct, but it seems to me that the “holistic” label is fading into the sunset. I never quite got what a holistic physician was doing that I wasn’t. Was I ignoring the fact that my patient came from a certain ethnic group and that his family had a particular set of religious beliefs? I may not have understood or agreed with those customs or beliefs. But I knew that I had better take them into account as I tried to find what was troubling the patient and help him search for a solution.

When the patient with frequent abdominal pains asked me for advice, did I fail to ask a social history because I didn’t think that the fact that her father had just lost his job or that her favorite grandmother was dying of cancer was important? Did I simply write prescriptions and avoid making recommendations about bedtimes, diet, exercise, and relaxation strategies? Did I stop my exam at the clavicles when the patient’s chief complaint was headache?

I’m sure that most physicians who marketed themselves as being holistic passionately believed that a good doctor must consider the whole patient. But what troubled me was the implication that the rest of us didn’t. I suspect that the fading popularity of the label reflects that patients began to realize that it was meaningless.

However, another buzzword has begun to flutter across the medical landscape. Every few days I open a magazine or journal in which someone is suggesting that I need to be more mindful. And they are more than willing to show me or sell me a technique for achieving mindfulness.

Is this just another packaging ploy, or should I begin paddling out to catch this new wave? The more I began to see mindfulness offered and promoted in a wider variety of settings, the more confused I became. So I did what anyone with a WiFi connection would do. I Googled “mindfulness” and discovered that I had good reason to feel confused.

It turns out that in some form or another mindfulness has been a practice in the Buddhist tradition with a history dating back hundreds of years. The first definition I found in Wikipedia read: “being aware moment-to-moment of one’s subjective conscious experience from a first-person perspective.” However, as I read further I discovered a reference to no fewer than 13 disparate definitions across a spectrum from attention and awareness on one end to retention and remindfulness on the other.

Some advocates feel that meditation should be used to prepare oneself to be mindful or that meditation is integral to mindfulness. Other folks don’t seem to see meditation as particularly necessary.

There is a growing body of literature reporting that something labeled mindfulness has helped patients and practitioners improve one or more aspects of wellness. Although the quality of these reports varies widely, it suggests along with the long Buddhist tradition that there is something out there called mindfulness worth investigating.

However, I wonder why it is becoming so widely ballyhooed. It seems to me that at its core, being mindful is simply just trying to do a better job of paying attention to the world around us and our fellow inhabitants. Is it simply the flip side of an attention deficiency? Or, is it an attempt to give a more exotic and mysterious Asian-influenced label to cognitive-behavioral therapy? Could it just be a less judgmental way of asking ourselves, “What were (are) you thinking?”

“Mindfulness” appears to have considerably more substance than “holistic,” but I fear that its indiscriminant use is going to damage its credibility. The overexposure has certainly triggered my skepticism.

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.”

I have had a long and circuitous relationship with the radius. When I was 9 years old, I slipped on the wet grass of our front yard in an attempt to make a highlight-reel baseball catch and landed awkwardly on my left arm. After I continued to complain for a day and a half, my mother took me to see our pediatrician, Dr. Blum. After feeling up and down my forearm and asking me to squeeze his fingers, he pronounced me well.

A week and a half later, when I was still favoring what is my dominant arm, we returned to Dr. Blum. Apparently still unimpressed with my physical exam, he begrudgingly ordered an x-ray. Hurrah! I had a fracture! But then he announced that we would treat it with a splint and an ace wrap. Come on! Everyone knows that if you break a bone you get a cast. From then on he was Dr. Bum to me.

For the next 2 weeks, I was forbidden to play sports, meanwhile losing serious credibility points with my peers who suspected that I was a wimp and had fabricated the whole story. And of course, does anyone go around asking their friends to sign his ace wrap ... really? It took me years of overcompensation to regain even a hint of preteen machismo.

During my last year of medical school, I leapt at the opportunity to take an elective in pediatric orthopedics. It was great! With coaching from the residents, I learned when to suspect a buckle fracture of the radius, identify it on x-ray, and best of all, how to apply a cast.

When I finally entered practice here in Brunswick, we were seriously short of specialists, including orthopedists. When it was discovered that I knew how to apply a forearm cast, the orthopedists encouraged me to treat my own patients with simple forearm fractures. They were more than busy enough with really exciting stuff.

As an artist at heart, the chance to mold in plaster and plastic was a special treat. I took great pride in my creations, and making a beautiful crafted cast was sometimes the high point of my day. No splints or wimpy ace wraps for my patients!

Parents loved the one-stop shopping. History, exam, x-ray, casting, and out the door in less than an hour. Because I was the only primary care physician in town who was casting fractures, I occasionally had to remind the emergency room physicians to send me my patients with buckle fractures instead of knee-jerking a referral to an orthopedist.

But then about 10 years ago, some party-pooping orthopedists from who-knows-where looked at a very large series of pediatric patients with buckle fractures of the radius and discovered that those patients treated with splints had at least as good results as those who had been casted. And ... the patients and parents preferred the splints. I had to admit that maybe Dr. Blum wasn’t such a bum after all. Sadly, I had to respond to the evidence by giving up my hobby except when a child’s temperament or past history of injury suggested that he or she might benefit from the extra protection a cast could afford.

A recent study from Toronto published in Pediatrics, “Primary Care Physician Follow-up of Distal Radius Buckle Fractures,” by Koelink et al., makes me wonder whether a splint and ace wrap may even be overtreatment (Pediatrics. 2016 Jan;137[1]:11-9. doi: 10.1542/peds.2015-2262). In this review of 200 pediatric patients with distal radius buckle fractures, the investigators found that regardless of whether the primary care physician discussed how long to use the splint or when to return to activity, more than two-thirds of the patients wore their splints less than 3 weeks. Despite what the authors considered suboptimal primary care physician guidance, 99% of the patients returned to usual activities within 4 weeks.

My mother and Dr. Blum were on the right track from the beginning. They just needed to ignore my complaints a few days longer.

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.”

I have had a long and circuitous relationship with the radius. When I was 9 years old, I slipped on the wet grass of our front yard in an attempt to make a highlight-reel baseball catch and landed awkwardly on my left arm. After I continued to complain for a day and a half, my mother took me to see our pediatrician, Dr. Blum. After feeling up and down my forearm and asking me to squeeze his fingers, he pronounced me well.

A week and a half later, when I was still favoring what is my dominant arm, we returned to Dr. Blum. Apparently still unimpressed with my physical exam, he begrudgingly ordered an x-ray. Hurrah! I had a fracture! But then he announced that we would treat it with a splint and an ace wrap. Come on! Everyone knows that if you break a bone you get a cast. From then on he was Dr. Bum to me.

For the next 2 weeks, I was forbidden to play sports, meanwhile losing serious credibility points with my peers who suspected that I was a wimp and had fabricated the whole story. And of course, does anyone go around asking their friends to sign his ace wrap ... really? It took me years of overcompensation to regain even a hint of preteen machismo.

During my last year of medical school, I leapt at the opportunity to take an elective in pediatric orthopedics. It was great! With coaching from the residents, I learned when to suspect a buckle fracture of the radius, identify it on x-ray, and best of all, how to apply a cast.

When I finally entered practice here in Brunswick, we were seriously short of specialists, including orthopedists. When it was discovered that I knew how to apply a forearm cast, the orthopedists encouraged me to treat my own patients with simple forearm fractures. They were more than busy enough with really exciting stuff.

As an artist at heart, the chance to mold in plaster and plastic was a special treat. I took great pride in my creations, and making a beautiful crafted cast was sometimes the high point of my day. No splints or wimpy ace wraps for my patients!

Parents loved the one-stop shopping. History, exam, x-ray, casting, and out the door in less than an hour. Because I was the only primary care physician in town who was casting fractures, I occasionally had to remind the emergency room physicians to send me my patients with buckle fractures instead of knee-jerking a referral to an orthopedist.

But then about 10 years ago, some party-pooping orthopedists from who-knows-where looked at a very large series of pediatric patients with buckle fractures of the radius and discovered that those patients treated with splints had at least as good results as those who had been casted. And ... the patients and parents preferred the splints. I had to admit that maybe Dr. Blum wasn’t such a bum after all. Sadly, I had to respond to the evidence by giving up my hobby except when a child’s temperament or past history of injury suggested that he or she might benefit from the extra protection a cast could afford.

A recent study from Toronto published in Pediatrics, “Primary Care Physician Follow-up of Distal Radius Buckle Fractures,” by Koelink et al., makes me wonder whether a splint and ace wrap may even be overtreatment (Pediatrics. 2016 Jan;137[1]:11-9. doi: 10.1542/peds.2015-2262). In this review of 200 pediatric patients with distal radius buckle fractures, the investigators found that regardless of whether the primary care physician discussed how long to use the splint or when to return to activity, more than two-thirds of the patients wore their splints less than 3 weeks. Despite what the authors considered suboptimal primary care physician guidance, 99% of the patients returned to usual activities within 4 weeks.

My mother and Dr. Blum were on the right track from the beginning. They just needed to ignore my complaints a few days longer.

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.”

I have had a long and circuitous relationship with the radius. When I was 9 years old, I slipped on the wet grass of our front yard in an attempt to make a highlight-reel baseball catch and landed awkwardly on my left arm. After I continued to complain for a day and a half, my mother took me to see our pediatrician, Dr. Blum. After feeling up and down my forearm and asking me to squeeze his fingers, he pronounced me well.

A week and a half later, when I was still favoring what is my dominant arm, we returned to Dr. Blum. Apparently still unimpressed with my physical exam, he begrudgingly ordered an x-ray. Hurrah! I had a fracture! But then he announced that we would treat it with a splint and an ace wrap. Come on! Everyone knows that if you break a bone you get a cast. From then on he was Dr. Bum to me.

For the next 2 weeks, I was forbidden to play sports, meanwhile losing serious credibility points with my peers who suspected that I was a wimp and had fabricated the whole story. And of course, does anyone go around asking their friends to sign his ace wrap ... really? It took me years of overcompensation to regain even a hint of preteen machismo.

During my last year of medical school, I leapt at the opportunity to take an elective in pediatric orthopedics. It was great! With coaching from the residents, I learned when to suspect a buckle fracture of the radius, identify it on x-ray, and best of all, how to apply a cast.

When I finally entered practice here in Brunswick, we were seriously short of specialists, including orthopedists. When it was discovered that I knew how to apply a forearm cast, the orthopedists encouraged me to treat my own patients with simple forearm fractures. They were more than busy enough with really exciting stuff.

As an artist at heart, the chance to mold in plaster and plastic was a special treat. I took great pride in my creations, and making a beautiful crafted cast was sometimes the high point of my day. No splints or wimpy ace wraps for my patients!

Parents loved the one-stop shopping. History, exam, x-ray, casting, and out the door in less than an hour. Because I was the only primary care physician in town who was casting fractures, I occasionally had to remind the emergency room physicians to send me my patients with buckle fractures instead of knee-jerking a referral to an orthopedist.

But then about 10 years ago, some party-pooping orthopedists from who-knows-where looked at a very large series of pediatric patients with buckle fractures of the radius and discovered that those patients treated with splints had at least as good results as those who had been casted. And ... the patients and parents preferred the splints. I had to admit that maybe Dr. Blum wasn’t such a bum after all. Sadly, I had to respond to the evidence by giving up my hobby except when a child’s temperament or past history of injury suggested that he or she might benefit from the extra protection a cast could afford.

A recent study from Toronto published in Pediatrics, “Primary Care Physician Follow-up of Distal Radius Buckle Fractures,” by Koelink et al., makes me wonder whether a splint and ace wrap may even be overtreatment (Pediatrics. 2016 Jan;137[1]:11-9. doi: 10.1542/peds.2015-2262). In this review of 200 pediatric patients with distal radius buckle fractures, the investigators found that regardless of whether the primary care physician discussed how long to use the splint or when to return to activity, more than two-thirds of the patients wore their splints less than 3 weeks. Despite what the authors considered suboptimal primary care physician guidance, 99% of the patients returned to usual activities within 4 weeks.

My mother and Dr. Blum were on the right track from the beginning. They just needed to ignore my complaints a few days longer.

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.”