Letters from Maine

Brunswick, Maine, is a soccer town. Before 1970 it was a football town because that was the only game in town. But soccer rose in popularity, and now the Dragons are perennial contenders for and frequent winners of the State Class A title. Football faded and just barely survived.

Fortunately, my children began playing soccer when the sport was still a one-season activity. They were skilled enough to play on the early elite teams that rarely traveled across county or state lines to compete. But with each passing year, I have watched many of my patients being asked to make ever-greater commitments to soccer. A spring season was added to the traditional fall season, and indoor facilities were built. Now any child who seriously wants to play in high school is expected to sharpen his or her skills in a winter league. Elite teams now travel routinely out of state for weekend-long tournaments.

©photoaged/FOTOLIA

While some children abandon other sports when they are in middle school to put their eggs in the soccer basket, thankfully the majority continue to play one or two other sports in high school. I know that this trend toward premature overspecialization has reached further heights of absurdity in other communities. Luckily, Brunswick is a small town in a small state that is often shielded from some of the strongest winds of change.

However, the gale is growing stronger. The United States Soccer Federation has tilted the field even more toward premature overspecialization. A youngster who wants to participate in one of the federation’s U.S. Soccer Development Academies must commit to a nearly year-round season that effectively eliminates their ability to play for their school teams. They must become a soccer player and not much else.

One could argue that by skimming off the cream of the crop, more of the normally gifted athletes will have a chance to participate. However, this plus is microscopic compared to fate of the unfortunate one-trick ponies who have been robbed of the sense of community that comes when a student can play for his own school team.

One must wonder if premature overspecialization might also increase the risk of injury, an injury that might not have occurred had the youngster not burned his bridges to other sports. Even if one shares the vision of improving our ability to compete on the international stage, one must consider how many exceptional professional athletes excelled in several sports in high school. The strategy fails to acknowledge the well-known phenomenon of cross-sport skill development. And, are we now to believe that late-bloomers have become extinct?

While formalizing and fostering premature overspecialization seem like a bad idea to me now, I must admit that early in my parenting career I had a different view. Every parent who notices that his child can kick a ball farther than his preschool peers can fall victim to the seduction. Visions of Division I scholarships and professional signing bonuses can cloud a new parent’s fertile mind. Decisions to overcommit a child’s time and a family’s resources to a single activity can accumulate unchecked by reality. Sadly, when one child seems to have exceptional skills, siblings are relegated to a life as traveling spectators. Luckily, I was rescued by my wife and three children, whose good sense equaled their exceptional athletic skills.

Is this an issue for pediatricians to address with parents? Obviously, it pales in comparison to decisions about immunizations. But, I don’t hesitate to carefully share my views when the level of commitment seems to be having a negative influence on a child or his family.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

Brunswick, Maine, is a soccer town. Before 1970 it was a football town because that was the only game in town. But soccer rose in popularity, and now the Dragons are perennial contenders for and frequent winners of the State Class A title. Football faded and just barely survived.

Fortunately, my children began playing soccer when the sport was still a one-season activity. They were skilled enough to play on the early elite teams that rarely traveled across county or state lines to compete. But with each passing year, I have watched many of my patients being asked to make ever-greater commitments to soccer. A spring season was added to the traditional fall season, and indoor facilities were built. Now any child who seriously wants to play in high school is expected to sharpen his or her skills in a winter league. Elite teams now travel routinely out of state for weekend-long tournaments.

©photoaged/FOTOLIA

While some children abandon other sports when they are in middle school to put their eggs in the soccer basket, thankfully the majority continue to play one or two other sports in high school. I know that this trend toward premature overspecialization has reached further heights of absurdity in other communities. Luckily, Brunswick is a small town in a small state that is often shielded from some of the strongest winds of change.

However, the gale is growing stronger. The United States Soccer Federation has tilted the field even more toward premature overspecialization. A youngster who wants to participate in one of the federation’s U.S. Soccer Development Academies must commit to a nearly year-round season that effectively eliminates their ability to play for their school teams. They must become a soccer player and not much else.

One could argue that by skimming off the cream of the crop, more of the normally gifted athletes will have a chance to participate. However, this plus is microscopic compared to fate of the unfortunate one-trick ponies who have been robbed of the sense of community that comes when a student can play for his own school team.

One must wonder if premature overspecialization might also increase the risk of injury, an injury that might not have occurred had the youngster not burned his bridges to other sports. Even if one shares the vision of improving our ability to compete on the international stage, one must consider how many exceptional professional athletes excelled in several sports in high school. The strategy fails to acknowledge the well-known phenomenon of cross-sport skill development. And, are we now to believe that late-bloomers have become extinct?

While formalizing and fostering premature overspecialization seem like a bad idea to me now, I must admit that early in my parenting career I had a different view. Every parent who notices that his child can kick a ball farther than his preschool peers can fall victim to the seduction. Visions of Division I scholarships and professional signing bonuses can cloud a new parent’s fertile mind. Decisions to overcommit a child’s time and a family’s resources to a single activity can accumulate unchecked by reality. Sadly, when one child seems to have exceptional skills, siblings are relegated to a life as traveling spectators. Luckily, I was rescued by my wife and three children, whose good sense equaled their exceptional athletic skills.

Is this an issue for pediatricians to address with parents? Obviously, it pales in comparison to decisions about immunizations. But, I don’t hesitate to carefully share my views when the level of commitment seems to be having a negative influence on a child or his family.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

Brunswick, Maine, is a soccer town. Before 1970 it was a football town because that was the only game in town. But soccer rose in popularity, and now the Dragons are perennial contenders for and frequent winners of the State Class A title. Football faded and just barely survived.

Fortunately, my children began playing soccer when the sport was still a one-season activity. They were skilled enough to play on the early elite teams that rarely traveled across county or state lines to compete. But with each passing year, I have watched many of my patients being asked to make ever-greater commitments to soccer. A spring season was added to the traditional fall season, and indoor facilities were built. Now any child who seriously wants to play in high school is expected to sharpen his or her skills in a winter league. Elite teams now travel routinely out of state for weekend-long tournaments.

©photoaged/FOTOLIA

While some children abandon other sports when they are in middle school to put their eggs in the soccer basket, thankfully the majority continue to play one or two other sports in high school. I know that this trend toward premature overspecialization has reached further heights of absurdity in other communities. Luckily, Brunswick is a small town in a small state that is often shielded from some of the strongest winds of change.

However, the gale is growing stronger. The United States Soccer Federation has tilted the field even more toward premature overspecialization. A youngster who wants to participate in one of the federation’s U.S. Soccer Development Academies must commit to a nearly year-round season that effectively eliminates their ability to play for their school teams. They must become a soccer player and not much else.

One could argue that by skimming off the cream of the crop, more of the normally gifted athletes will have a chance to participate. However, this plus is microscopic compared to fate of the unfortunate one-trick ponies who have been robbed of the sense of community that comes when a student can play for his own school team.

One must wonder if premature overspecialization might also increase the risk of injury, an injury that might not have occurred had the youngster not burned his bridges to other sports. Even if one shares the vision of improving our ability to compete on the international stage, one must consider how many exceptional professional athletes excelled in several sports in high school. The strategy fails to acknowledge the well-known phenomenon of cross-sport skill development. And, are we now to believe that late-bloomers have become extinct?

While formalizing and fostering premature overspecialization seem like a bad idea to me now, I must admit that early in my parenting career I had a different view. Every parent who notices that his child can kick a ball farther than his preschool peers can fall victim to the seduction. Visions of Division I scholarships and professional signing bonuses can cloud a new parent’s fertile mind. Decisions to overcommit a child’s time and a family’s resources to a single activity can accumulate unchecked by reality. Sadly, when one child seems to have exceptional skills, siblings are relegated to a life as traveling spectators. Luckily, I was rescued by my wife and three children, whose good sense equaled their exceptional athletic skills.

Is this an issue for pediatricians to address with parents? Obviously, it pales in comparison to decisions about immunizations. But, I don’t hesitate to carefully share my views when the level of commitment seems to be having a negative influence on a child or his family.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

It was long overdue and for my tastes a bit watered down, but I must say that the American Academy of Pediatrics’ recent policy statement on sensory integration therapies (Pediatrics 2012;129:1186-89) is a nice piece of work. It stops short of saying that sensory integration therapies have little or no value. But, I guess I can defend their cautious approach. While there don’t seem to be any good studies to support those therapies, there is always a small chance that they might help the rare child with developmental and/or emotional problems. Over the last 30-plus years, I haven’t observed any situations in which therapies such as brushing or textured diets have helped. But then I may have nodded off once or twice.

The policy statement includes some broad recommendations on how pediatricians might wean families off therapeutic regimens that aren’t working. It mentions education and setting time limits after which pediatricians and parents should revisit the decision to continue the therapy and ask if it has been meeting stated goals.

I think it would have been helpful to include in the statement some sample language and talking points to assist in the process. Not all of us, myself certainly included, can always come up with the best words in situations like this. I fear that on a bad day I might say something like, "That stuff is bunk!" and figure that the issue was dead. Of course most parents will understandably recoil at such insensitivity, and I will have lost any chance I might have had in getting the ship going in a better direction.

The unfortunate irony hidden in the whole sensory integration rat’s nest is that while the therapies probably have little value, the label of "disorder" can be reassuring to many parents. For years they may have struggled to figure out how to help their child who has seemed different. When an occupational therapist describes to a parent the features of a typical child with a "sensory integration disorder," it may be the first time anyone has said or implied, "You aren’t alone. There are other children who behave this way. In fact we have a name for it."

The problem comes when the therapist takes the next step and says, "And there are some therapies that we can do to help it." The problem is that the evidence doesn’t support that leap from label to therapy. What we need is a new set of labels that avoid words like "disorder" or "syndrome," which might suggest that some therapy or intervention is necessary.

Most, if not all, of the children I have seen whose primary diagnosis is a sensory integration disorder are normal. They may be extremely sensitive to sounds or textures or tastes or smells or being touched or all of the above. But they are normal and with time will lose some and maybe all of that hypersensitivity. What they need is to be understood. They will benefit from having their environment adjusted to accommodate their peculiarities (not abnormalities). Until they mature. Parents, teachers, relatives, and caregivers must be coached to change their expectations.

The hypersensitive child may not do well in the relative chaos that his older brother has thrived in. He may not accept textures that his omnivorous sister devoured. He may require more space than his classmates. Maybe his behavior is a manifestation of anxiety ... probably the greatest mimic in the cast of emotional actors.

Unfortunately, it is often difficult for all of us to ignore or abandon an active (but ineffective) intervention and accept a strategy that includes patience, altering expectations, and adjusting lifestyles. One could argue, "What damage is done by continuing a therapy that may not have been proved effective, but seems to be harmless?" My answer would be that these therapies are probably diverting parental attention, and siphoning time and resources away from activities that will be more beneficial to the child and his family.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

It was long overdue and for my tastes a bit watered down, but I must say that the American Academy of Pediatrics’ recent policy statement on sensory integration therapies (Pediatrics 2012;129:1186-89) is a nice piece of work. It stops short of saying that sensory integration therapies have little or no value. But, I guess I can defend their cautious approach. While there don’t seem to be any good studies to support those therapies, there is always a small chance that they might help the rare child with developmental and/or emotional problems. Over the last 30-plus years, I haven’t observed any situations in which therapies such as brushing or textured diets have helped. But then I may have nodded off once or twice.

The policy statement includes some broad recommendations on how pediatricians might wean families off therapeutic regimens that aren’t working. It mentions education and setting time limits after which pediatricians and parents should revisit the decision to continue the therapy and ask if it has been meeting stated goals.

I think it would have been helpful to include in the statement some sample language and talking points to assist in the process. Not all of us, myself certainly included, can always come up with the best words in situations like this. I fear that on a bad day I might say something like, "That stuff is bunk!" and figure that the issue was dead. Of course most parents will understandably recoil at such insensitivity, and I will have lost any chance I might have had in getting the ship going in a better direction.

The unfortunate irony hidden in the whole sensory integration rat’s nest is that while the therapies probably have little value, the label of "disorder" can be reassuring to many parents. For years they may have struggled to figure out how to help their child who has seemed different. When an occupational therapist describes to a parent the features of a typical child with a "sensory integration disorder," it may be the first time anyone has said or implied, "You aren’t alone. There are other children who behave this way. In fact we have a name for it."

The problem comes when the therapist takes the next step and says, "And there are some therapies that we can do to help it." The problem is that the evidence doesn’t support that leap from label to therapy. What we need is a new set of labels that avoid words like "disorder" or "syndrome," which might suggest that some therapy or intervention is necessary.

Most, if not all, of the children I have seen whose primary diagnosis is a sensory integration disorder are normal. They may be extremely sensitive to sounds or textures or tastes or smells or being touched or all of the above. But they are normal and with time will lose some and maybe all of that hypersensitivity. What they need is to be understood. They will benefit from having their environment adjusted to accommodate their peculiarities (not abnormalities). Until they mature. Parents, teachers, relatives, and caregivers must be coached to change their expectations.

The hypersensitive child may not do well in the relative chaos that his older brother has thrived in. He may not accept textures that his omnivorous sister devoured. He may require more space than his classmates. Maybe his behavior is a manifestation of anxiety ... probably the greatest mimic in the cast of emotional actors.

Unfortunately, it is often difficult for all of us to ignore or abandon an active (but ineffective) intervention and accept a strategy that includes patience, altering expectations, and adjusting lifestyles. One could argue, "What damage is done by continuing a therapy that may not have been proved effective, but seems to be harmless?" My answer would be that these therapies are probably diverting parental attention, and siphoning time and resources away from activities that will be more beneficial to the child and his family.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

It was long overdue and for my tastes a bit watered down, but I must say that the American Academy of Pediatrics’ recent policy statement on sensory integration therapies (Pediatrics 2012;129:1186-89) is a nice piece of work. It stops short of saying that sensory integration therapies have little or no value. But, I guess I can defend their cautious approach. While there don’t seem to be any good studies to support those therapies, there is always a small chance that they might help the rare child with developmental and/or emotional problems. Over the last 30-plus years, I haven’t observed any situations in which therapies such as brushing or textured diets have helped. But then I may have nodded off once or twice.

The policy statement includes some broad recommendations on how pediatricians might wean families off therapeutic regimens that aren’t working. It mentions education and setting time limits after which pediatricians and parents should revisit the decision to continue the therapy and ask if it has been meeting stated goals.

I think it would have been helpful to include in the statement some sample language and talking points to assist in the process. Not all of us, myself certainly included, can always come up with the best words in situations like this. I fear that on a bad day I might say something like, "That stuff is bunk!" and figure that the issue was dead. Of course most parents will understandably recoil at such insensitivity, and I will have lost any chance I might have had in getting the ship going in a better direction.

The unfortunate irony hidden in the whole sensory integration rat’s nest is that while the therapies probably have little value, the label of "disorder" can be reassuring to many parents. For years they may have struggled to figure out how to help their child who has seemed different. When an occupational therapist describes to a parent the features of a typical child with a "sensory integration disorder," it may be the first time anyone has said or implied, "You aren’t alone. There are other children who behave this way. In fact we have a name for it."

The problem comes when the therapist takes the next step and says, "And there are some therapies that we can do to help it." The problem is that the evidence doesn’t support that leap from label to therapy. What we need is a new set of labels that avoid words like "disorder" or "syndrome," which might suggest that some therapy or intervention is necessary.

Most, if not all, of the children I have seen whose primary diagnosis is a sensory integration disorder are normal. They may be extremely sensitive to sounds or textures or tastes or smells or being touched or all of the above. But they are normal and with time will lose some and maybe all of that hypersensitivity. What they need is to be understood. They will benefit from having their environment adjusted to accommodate their peculiarities (not abnormalities). Until they mature. Parents, teachers, relatives, and caregivers must be coached to change their expectations.

The hypersensitive child may not do well in the relative chaos that his older brother has thrived in. He may not accept textures that his omnivorous sister devoured. He may require more space than his classmates. Maybe his behavior is a manifestation of anxiety ... probably the greatest mimic in the cast of emotional actors.

Unfortunately, it is often difficult for all of us to ignore or abandon an active (but ineffective) intervention and accept a strategy that includes patience, altering expectations, and adjusting lifestyles. One could argue, "What damage is done by continuing a therapy that may not have been proved effective, but seems to be harmless?" My answer would be that these therapies are probably diverting parental attention, and siphoning time and resources away from activities that will be more beneficial to the child and his family.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

A few months ago I was having lunch with a pediatrician who has more than 30 years of practice behind him. In addition to swapping war stories from the trenches and bragging about our grandchildren, we shared our long-range views of where pediatrics has been and where it is going.

One of the things we agreed on was that anxiety has been one of the primary emotions, if not the primary emotion, driving the problems we have seen in the office. It is tempting to place depression at the top of the list, particularly if you see a lot of teenagers in your practice. And of course one could argue that there is abundant evidence of the unfortunate effects that parental depression can have on the health of children. However, what makes anxiety stand out is that patients have a frustrating ability of burying it beneath a complex array of complaints. My friend and I may have been more correct to agree that anxiety is the most underappreciated emotion on the diagnostic menu.

For example, consider the child who is missing school frequently because of abdominal pain. She is on her expected growth curve and has unremarkable bowel movements. Would the experienced pediatrician send that patient to the gastroenterologist, or begin asking how things are going at school? Has a parent been sick or been away on business trips?

And what about the 6-year-old who suddenly begins making frequent trips to the bathroom to urinate, but sleeps through the night dry? I guess most of us would obtain a urine sample that we know is going to be normal. Old habits die hard. But the rest of the visit should be spent exploring whether he or a classmate has had a urine accident recently. Even a minor slip can trigger a fear that, "if I don’t keep my bladder empty, it’s going to happen to me."

And of course there are the legions of constipated stool retainers. To my way of thinking, most of these children have an anxiety problem. Rarely is there an obvious history of a painful bowel movement. But we have all known children who have passed many painful stools who don’t become so fearful that they decide not going to the bathroom is the better option. However, there is that group of children cursed with such a deeply ingrained anxiety about the pain that it will take a year or more of laxative-aided bowel movements to eradicate it. It is interesting that the solution is not SSRIs or extended counseling. I have seen both fail. There is a message there that I haven’t quite figured out yet.

Separation anxiety seems to be a normal part of the tool kit that babies are born with. The problem is that many parents have lost the tools in their kits to deal with it. The result can be years of lost sleep for entire families. Even for the parents who have mastered the challenge of saying good night or good-bye, a serious parental illness or longer-than-usual separation can reignite the child’s anxiety.

I have seen children who have refused to play outside because they have become afraid of clouds or butterflies. And there are those patients who have begun to refuse solids because of a minor choking episode. I’m sure you could add to the list and have your own tricks for managing them.

But no discussion of the power of anxiety would be complete without a mention of how our behavior as physicians is molded by fear. We can thank lawyers and, to some extent, ourselves for not coming to grips with that reality. Knowledge can be a potent anxiolytic. But we need a coordinated health delivery plan that can give us some protection or defensive medicine is going to keep costs spiraling upward. That is something to really fear.

A few months ago I was having lunch with a pediatrician who has more than 30 years of practice behind him. In addition to swapping war stories from the trenches and bragging about our grandchildren, we shared our long-range views of where pediatrics has been and where it is going.

One of the things we agreed on was that anxiety has been one of the primary emotions, if not the primary emotion, driving the problems we have seen in the office. It is tempting to place depression at the top of the list, particularly if you see a lot of teenagers in your practice. And of course one could argue that there is abundant evidence of the unfortunate effects that parental depression can have on the health of children. However, what makes anxiety stand out is that patients have a frustrating ability of burying it beneath a complex array of complaints. My friend and I may have been more correct to agree that anxiety is the most underappreciated emotion on the diagnostic menu.

For example, consider the child who is missing school frequently because of abdominal pain. She is on her expected growth curve and has unremarkable bowel movements. Would the experienced pediatrician send that patient to the gastroenterologist, or begin asking how things are going at school? Has a parent been sick or been away on business trips?

And what about the 6-year-old who suddenly begins making frequent trips to the bathroom to urinate, but sleeps through the night dry? I guess most of us would obtain a urine sample that we know is going to be normal. Old habits die hard. But the rest of the visit should be spent exploring whether he or a classmate has had a urine accident recently. Even a minor slip can trigger a fear that, "if I don’t keep my bladder empty, it’s going to happen to me."

And of course there are the legions of constipated stool retainers. To my way of thinking, most of these children have an anxiety problem. Rarely is there an obvious history of a painful bowel movement. But we have all known children who have passed many painful stools who don’t become so fearful that they decide not going to the bathroom is the better option. However, there is that group of children cursed with such a deeply ingrained anxiety about the pain that it will take a year or more of laxative-aided bowel movements to eradicate it. It is interesting that the solution is not SSRIs or extended counseling. I have seen both fail. There is a message there that I haven’t quite figured out yet.

Separation anxiety seems to be a normal part of the tool kit that babies are born with. The problem is that many parents have lost the tools in their kits to deal with it. The result can be years of lost sleep for entire families. Even for the parents who have mastered the challenge of saying good night or good-bye, a serious parental illness or longer-than-usual separation can reignite the child’s anxiety.

I have seen children who have refused to play outside because they have become afraid of clouds or butterflies. And there are those patients who have begun to refuse solids because of a minor choking episode. I’m sure you could add to the list and have your own tricks for managing them.

But no discussion of the power of anxiety would be complete without a mention of how our behavior as physicians is molded by fear. We can thank lawyers and, to some extent, ourselves for not coming to grips with that reality. Knowledge can be a potent anxiolytic. But we need a coordinated health delivery plan that can give us some protection or defensive medicine is going to keep costs spiraling upward. That is something to really fear.

A few months ago I was having lunch with a pediatrician who has more than 30 years of practice behind him. In addition to swapping war stories from the trenches and bragging about our grandchildren, we shared our long-range views of where pediatrics has been and where it is going.

One of the things we agreed on was that anxiety has been one of the primary emotions, if not the primary emotion, driving the problems we have seen in the office. It is tempting to place depression at the top of the list, particularly if you see a lot of teenagers in your practice. And of course one could argue that there is abundant evidence of the unfortunate effects that parental depression can have on the health of children. However, what makes anxiety stand out is that patients have a frustrating ability of burying it beneath a complex array of complaints. My friend and I may have been more correct to agree that anxiety is the most underappreciated emotion on the diagnostic menu.

For example, consider the child who is missing school frequently because of abdominal pain. She is on her expected growth curve and has unremarkable bowel movements. Would the experienced pediatrician send that patient to the gastroenterologist, or begin asking how things are going at school? Has a parent been sick or been away on business trips?

And what about the 6-year-old who suddenly begins making frequent trips to the bathroom to urinate, but sleeps through the night dry? I guess most of us would obtain a urine sample that we know is going to be normal. Old habits die hard. But the rest of the visit should be spent exploring whether he or a classmate has had a urine accident recently. Even a minor slip can trigger a fear that, "if I don’t keep my bladder empty, it’s going to happen to me."

And of course there are the legions of constipated stool retainers. To my way of thinking, most of these children have an anxiety problem. Rarely is there an obvious history of a painful bowel movement. But we have all known children who have passed many painful stools who don’t become so fearful that they decide not going to the bathroom is the better option. However, there is that group of children cursed with such a deeply ingrained anxiety about the pain that it will take a year or more of laxative-aided bowel movements to eradicate it. It is interesting that the solution is not SSRIs or extended counseling. I have seen both fail. There is a message there that I haven’t quite figured out yet.

Separation anxiety seems to be a normal part of the tool kit that babies are born with. The problem is that many parents have lost the tools in their kits to deal with it. The result can be years of lost sleep for entire families. Even for the parents who have mastered the challenge of saying good night or good-bye, a serious parental illness or longer-than-usual separation can reignite the child’s anxiety.

I have seen children who have refused to play outside because they have become afraid of clouds or butterflies. And there are those patients who have begun to refuse solids because of a minor choking episode. I’m sure you could add to the list and have your own tricks for managing them.

But no discussion of the power of anxiety would be complete without a mention of how our behavior as physicians is molded by fear. We can thank lawyers and, to some extent, ourselves for not coming to grips with that reality. Knowledge can be a potent anxiolytic. But we need a coordinated health delivery plan that can give us some protection or defensive medicine is going to keep costs spiraling upward. That is something to really fear.

Northern New Englanders enjoy befuddling tourists by telling them, "You can’t get there from here." Closer to the truth is the observation that when you leave Maine by plane, it will take you at least a full day regardless of your destination. Our remote location and terrorist-induced paranoia guarantee that I am going to spend a large chunk of my travel day sitting in airport terminals. I plan ahead by stockpiling unread copies of Pediatrics in Review, but they lose their appeal after a few hours. This leaves me enough time to observe the river of humanity streaming down the airport concourses.

How did we allow ourselves to get so fat? "Have you thought about what that tattoo is going to look like in 20 years?" Every few minutes the torrent of travelers divides to flow around a knot of people who have stopped to play out a little scenario for my entertainment.

On my last trip, a young family with a 2-year-old in tow was moving easily with the flow when the toddler stopped suddenly to look at the cowboy in full regalia sitting across from me. One bark and tug on her hand by her mother and they continued on down the concourse.

I’m sure it was a nonevent to anyone else who saw it. But to a pediatrician with time to kill, this ripple in the traffic flow was food for thought. What if the mother had jerked a little more firmly? A tearful little girl with her left arm hanging limply at her side would be standing within my arm’s reach.

Had this occurred on the grassy mall in the center of Brunswick, there is no question what I would do. If the mother didn’t recognize me, I would introduce myself and reduce the joint on the spot. But this was a very different environment. While I don’t look like someone who has just staggered out of a biker bar, I was bereft of any doctor paraphernalia. I carry my American Academy of Pediatrics card in my wallet. But have you looked at yours lately? Mine is a pretty sad and flimsy excuse for an ID. I’d be more likely to convince this mother of my authenticity with my AARP card.

In today’s litigious climate, should I even bother to intervene? The injury was minor. As long as the child could keep her arm at her side, she would be comfortable. Eventually, her family would find their way to an ED or an urgent care center. The elbow might even pop in place on its own. But this was going to put a major wrinkle in this family’s travel plans. She might have a needless x-ray. If she were lucky, she would be seen by a physician who could correctly diagnose and reduce this subluxation on the first attempt. But it could be worse.

What were my risks? My lifetime success rate at reduction is 99%. It’s actually 100% in the last 20 years, since I adopted the habit of keeping the child’s elbow flexed for at least 5 minutes after I felt the reassuring pop. At home I order an x-ray only if the injury was unwitnessed and I am uncomfortable with my exam.

But here I was in a strange town facing parents who didn’t know me from Adam. If they trusted me, could I trust them? Were they traveling from a state with an unfavorable malpractice history? The chances that I would do more harm than good were slim. The fact that our society has reached a place in which I was even having to think this through depressed me more than watching the parade of obesity.

During our vacation, I continued to mull my hypothetical dilemma. Eventually, I decided that I would introduce myself, describe the child’s problem, and explain how it could be fixed. I would suggest that if they had a choice when they reached their destination they seek out a pediatrician instead of going to an ED. But I would stop short of offering to do the reduction myself.

I’m still not happy with my solution, but I guess that’s the definition of a compromise. I would enjoy hearing what you would have done on that airport concourse.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. 

Northern New Englanders enjoy befuddling tourists by telling them, "You can’t get there from here." Closer to the truth is the observation that when you leave Maine by plane, it will take you at least a full day regardless of your destination. Our remote location and terrorist-induced paranoia guarantee that I am going to spend a large chunk of my travel day sitting in airport terminals. I plan ahead by stockpiling unread copies of Pediatrics in Review, but they lose their appeal after a few hours. This leaves me enough time to observe the river of humanity streaming down the airport concourses.

How did we allow ourselves to get so fat? "Have you thought about what that tattoo is going to look like in 20 years?" Every few minutes the torrent of travelers divides to flow around a knot of people who have stopped to play out a little scenario for my entertainment.

On my last trip, a young family with a 2-year-old in tow was moving easily with the flow when the toddler stopped suddenly to look at the cowboy in full regalia sitting across from me. One bark and tug on her hand by her mother and they continued on down the concourse.

I’m sure it was a nonevent to anyone else who saw it. But to a pediatrician with time to kill, this ripple in the traffic flow was food for thought. What if the mother had jerked a little more firmly? A tearful little girl with her left arm hanging limply at her side would be standing within my arm’s reach.

Had this occurred on the grassy mall in the center of Brunswick, there is no question what I would do. If the mother didn’t recognize me, I would introduce myself and reduce the joint on the spot. But this was a very different environment. While I don’t look like someone who has just staggered out of a biker bar, I was bereft of any doctor paraphernalia. I carry my American Academy of Pediatrics card in my wallet. But have you looked at yours lately? Mine is a pretty sad and flimsy excuse for an ID. I’d be more likely to convince this mother of my authenticity with my AARP card.

In today’s litigious climate, should I even bother to intervene? The injury was minor. As long as the child could keep her arm at her side, she would be comfortable. Eventually, her family would find their way to an ED or an urgent care center. The elbow might even pop in place on its own. But this was going to put a major wrinkle in this family’s travel plans. She might have a needless x-ray. If she were lucky, she would be seen by a physician who could correctly diagnose and reduce this subluxation on the first attempt. But it could be worse.

What were my risks? My lifetime success rate at reduction is 99%. It’s actually 100% in the last 20 years, since I adopted the habit of keeping the child’s elbow flexed for at least 5 minutes after I felt the reassuring pop. At home I order an x-ray only if the injury was unwitnessed and I am uncomfortable with my exam.

But here I was in a strange town facing parents who didn’t know me from Adam. If they trusted me, could I trust them? Were they traveling from a state with an unfavorable malpractice history? The chances that I would do more harm than good were slim. The fact that our society has reached a place in which I was even having to think this through depressed me more than watching the parade of obesity.

During our vacation, I continued to mull my hypothetical dilemma. Eventually, I decided that I would introduce myself, describe the child’s problem, and explain how it could be fixed. I would suggest that if they had a choice when they reached their destination they seek out a pediatrician instead of going to an ED. But I would stop short of offering to do the reduction myself.

I’m still not happy with my solution, but I guess that’s the definition of a compromise. I would enjoy hearing what you would have done on that airport concourse.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. 

Northern New Englanders enjoy befuddling tourists by telling them, "You can’t get there from here." Closer to the truth is the observation that when you leave Maine by plane, it will take you at least a full day regardless of your destination. Our remote location and terrorist-induced paranoia guarantee that I am going to spend a large chunk of my travel day sitting in airport terminals. I plan ahead by stockpiling unread copies of Pediatrics in Review, but they lose their appeal after a few hours. This leaves me enough time to observe the river of humanity streaming down the airport concourses.

How did we allow ourselves to get so fat? "Have you thought about what that tattoo is going to look like in 20 years?" Every few minutes the torrent of travelers divides to flow around a knot of people who have stopped to play out a little scenario for my entertainment.

On my last trip, a young family with a 2-year-old in tow was moving easily with the flow when the toddler stopped suddenly to look at the cowboy in full regalia sitting across from me. One bark and tug on her hand by her mother and they continued on down the concourse.

I’m sure it was a nonevent to anyone else who saw it. But to a pediatrician with time to kill, this ripple in the traffic flow was food for thought. What if the mother had jerked a little more firmly? A tearful little girl with her left arm hanging limply at her side would be standing within my arm’s reach.

Had this occurred on the grassy mall in the center of Brunswick, there is no question what I would do. If the mother didn’t recognize me, I would introduce myself and reduce the joint on the spot. But this was a very different environment. While I don’t look like someone who has just staggered out of a biker bar, I was bereft of any doctor paraphernalia. I carry my American Academy of Pediatrics card in my wallet. But have you looked at yours lately? Mine is a pretty sad and flimsy excuse for an ID. I’d be more likely to convince this mother of my authenticity with my AARP card.

In today’s litigious climate, should I even bother to intervene? The injury was minor. As long as the child could keep her arm at her side, she would be comfortable. Eventually, her family would find their way to an ED or an urgent care center. The elbow might even pop in place on its own. But this was going to put a major wrinkle in this family’s travel plans. She might have a needless x-ray. If she were lucky, she would be seen by a physician who could correctly diagnose and reduce this subluxation on the first attempt. But it could be worse.

What were my risks? My lifetime success rate at reduction is 99%. It’s actually 100% in the last 20 years, since I adopted the habit of keeping the child’s elbow flexed for at least 5 minutes after I felt the reassuring pop. At home I order an x-ray only if the injury was unwitnessed and I am uncomfortable with my exam.

But here I was in a strange town facing parents who didn’t know me from Adam. If they trusted me, could I trust them? Were they traveling from a state with an unfavorable malpractice history? The chances that I would do more harm than good were slim. The fact that our society has reached a place in which I was even having to think this through depressed me more than watching the parade of obesity.

During our vacation, I continued to mull my hypothetical dilemma. Eventually, I decided that I would introduce myself, describe the child’s problem, and explain how it could be fixed. I would suggest that if they had a choice when they reached their destination they seek out a pediatrician instead of going to an ED. But I would stop short of offering to do the reduction myself.

I’m still not happy with my solution, but I guess that’s the definition of a compromise. I would enjoy hearing what you would have done on that airport concourse.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. 

If you haven’t seen the May 21, 2012, cover of Time Magazine, take a look. Standing on a short chair is a young boy who looks like he could be 4 years old (he is alleged to be younger) suckling his mother’s left breast. She is a willowy blond who looks as though she is on a short break from a fashion magazine shoot. Regardless of your perspective, it is a striking image.

The cover story, "Are You Mom Enough?" addresses the phenomenon known variously as "attachment parenting" or "extreme mothering." If you practice in or around San Francisco, you are probably painfully aware of this trend. However, if your office is in Topeka you may not have dealt with a family who is practicing full contact attachment parenting ... yet. But I am sure you have dealt with parents whose style of parenting doesn’t quite sync with your own. How should a pediatrician deal with these discrepancies?

There has been a lot written and said about how pediatricians deal with the parents who choose to delay or decline immunizations. But when the differences in parenting style appear to lack the gravity of immunization choice, is this just a matter of different strokes for different folks? Should we maintain a professional silence and be content with sharing (HIPAA compliant, of course) anonymous anecdotes with our spouses? Or should we speak up and tactfully present an alternate strategy for parenting in a specific situation even though we may not have been asked for an opinion on the subject?

As the years have rolled by, I have broadened my view of how parenting should happen. Watching my brother-in-law and his wife raise their four children has been part of this education. Their decisions on activities, time management, and toy selection have been significantly different from those my wife and I had made. None of their decisions placed my nieces and nephews in danger, but they just weren’t the ones I would have made. Occasionally, when I was asked for an opinion, I would decline to offer one because they had already embarked on a path so different from the one I would have suggested that turning the ship around would have been difficult, if not impossible. The bottom line is that 20 years later, their children are growing into productive and considerate adults that I am proud to claim as nieces and nephews.

Although in general my views on parenting style have softened, there are some areas that have hardened. And some of these put me in conflict with attachment parenting advocates. I will admit that at some level seeing a 2½-year-old nursing makes me feel uncomfortable. But if that works for that family, I can accept it. The problem is that for every mother who can successfully allow nursing to occupy such a large chunk of her life, there are scores who have spent 1 or 2 years of their lives dangerously sleep deprived.

There are too many benefits of breastfeeding to include in this 500-word column. But mothers must not become human pacifiers. It may have worked when we were hunter-gatherers. But most families today can’t afford the flexibility that would allow a mother to be available to nurse her baby to sleep whenever the child is tired. In our society, when a mother’s breast becomes the primary comfort and sleep aid, something has to give and it is usually the mother’s sleep needs. Sleep-deprived mothers are usually not happy people. The evidence is mounting on the toll that depression takes on the health of the entire family.

So I continue to gently coach new mothers to try strategies that will allow them and their babies to enjoy the benefits of breastfeeding, and avoid the traps that can make parenting less enjoyable and effective.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

If you haven’t seen the May 21, 2012, cover of Time Magazine, take a look. Standing on a short chair is a young boy who looks like he could be 4 years old (he is alleged to be younger) suckling his mother’s left breast. She is a willowy blond who looks as though she is on a short break from a fashion magazine shoot. Regardless of your perspective, it is a striking image.

The cover story, "Are You Mom Enough?" addresses the phenomenon known variously as "attachment parenting" or "extreme mothering." If you practice in or around San Francisco, you are probably painfully aware of this trend. However, if your office is in Topeka you may not have dealt with a family who is practicing full contact attachment parenting ... yet. But I am sure you have dealt with parents whose style of parenting doesn’t quite sync with your own. How should a pediatrician deal with these discrepancies?

There has been a lot written and said about how pediatricians deal with the parents who choose to delay or decline immunizations. But when the differences in parenting style appear to lack the gravity of immunization choice, is this just a matter of different strokes for different folks? Should we maintain a professional silence and be content with sharing (HIPAA compliant, of course) anonymous anecdotes with our spouses? Or should we speak up and tactfully present an alternate strategy for parenting in a specific situation even though we may not have been asked for an opinion on the subject?

As the years have rolled by, I have broadened my view of how parenting should happen. Watching my brother-in-law and his wife raise their four children has been part of this education. Their decisions on activities, time management, and toy selection have been significantly different from those my wife and I had made. None of their decisions placed my nieces and nephews in danger, but they just weren’t the ones I would have made. Occasionally, when I was asked for an opinion, I would decline to offer one because they had already embarked on a path so different from the one I would have suggested that turning the ship around would have been difficult, if not impossible. The bottom line is that 20 years later, their children are growing into productive and considerate adults that I am proud to claim as nieces and nephews.

Although in general my views on parenting style have softened, there are some areas that have hardened. And some of these put me in conflict with attachment parenting advocates. I will admit that at some level seeing a 2½-year-old nursing makes me feel uncomfortable. But if that works for that family, I can accept it. The problem is that for every mother who can successfully allow nursing to occupy such a large chunk of her life, there are scores who have spent 1 or 2 years of their lives dangerously sleep deprived.

There are too many benefits of breastfeeding to include in this 500-word column. But mothers must not become human pacifiers. It may have worked when we were hunter-gatherers. But most families today can’t afford the flexibility that would allow a mother to be available to nurse her baby to sleep whenever the child is tired. In our society, when a mother’s breast becomes the primary comfort and sleep aid, something has to give and it is usually the mother’s sleep needs. Sleep-deprived mothers are usually not happy people. The evidence is mounting on the toll that depression takes on the health of the entire family.

So I continue to gently coach new mothers to try strategies that will allow them and their babies to enjoy the benefits of breastfeeding, and avoid the traps that can make parenting less enjoyable and effective.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

If you haven’t seen the May 21, 2012, cover of Time Magazine, take a look. Standing on a short chair is a young boy who looks like he could be 4 years old (he is alleged to be younger) suckling his mother’s left breast. She is a willowy blond who looks as though she is on a short break from a fashion magazine shoot. Regardless of your perspective, it is a striking image.

The cover story, "Are You Mom Enough?" addresses the phenomenon known variously as "attachment parenting" or "extreme mothering." If you practice in or around San Francisco, you are probably painfully aware of this trend. However, if your office is in Topeka you may not have dealt with a family who is practicing full contact attachment parenting ... yet. But I am sure you have dealt with parents whose style of parenting doesn’t quite sync with your own. How should a pediatrician deal with these discrepancies?

There has been a lot written and said about how pediatricians deal with the parents who choose to delay or decline immunizations. But when the differences in parenting style appear to lack the gravity of immunization choice, is this just a matter of different strokes for different folks? Should we maintain a professional silence and be content with sharing (HIPAA compliant, of course) anonymous anecdotes with our spouses? Or should we speak up and tactfully present an alternate strategy for parenting in a specific situation even though we may not have been asked for an opinion on the subject?

As the years have rolled by, I have broadened my view of how parenting should happen. Watching my brother-in-law and his wife raise their four children has been part of this education. Their decisions on activities, time management, and toy selection have been significantly different from those my wife and I had made. None of their decisions placed my nieces and nephews in danger, but they just weren’t the ones I would have made. Occasionally, when I was asked for an opinion, I would decline to offer one because they had already embarked on a path so different from the one I would have suggested that turning the ship around would have been difficult, if not impossible. The bottom line is that 20 years later, their children are growing into productive and considerate adults that I am proud to claim as nieces and nephews.

Although in general my views on parenting style have softened, there are some areas that have hardened. And some of these put me in conflict with attachment parenting advocates. I will admit that at some level seeing a 2½-year-old nursing makes me feel uncomfortable. But if that works for that family, I can accept it. The problem is that for every mother who can successfully allow nursing to occupy such a large chunk of her life, there are scores who have spent 1 or 2 years of their lives dangerously sleep deprived.

There are too many benefits of breastfeeding to include in this 500-word column. But mothers must not become human pacifiers. It may have worked when we were hunter-gatherers. But most families today can’t afford the flexibility that would allow a mother to be available to nurse her baby to sleep whenever the child is tired. In our society, when a mother’s breast becomes the primary comfort and sleep aid, something has to give and it is usually the mother’s sleep needs. Sleep-deprived mothers are usually not happy people. The evidence is mounting on the toll that depression takes on the health of the entire family.

So I continue to gently coach new mothers to try strategies that will allow them and their babies to enjoy the benefits of breastfeeding, and avoid the traps that can make parenting less enjoyable and effective.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

I was an art history major in college. The challenge of sorting out ancient Greek sculptures and Renaissance paintings suited my observational skills and avoided my difficulties with numbers. When it came time to practice medicine, it was clear that I would behave more like an artist than a scientist. I have stubbornly resisted requests to attach numbers to things that don’t warrant their specificity.

But, not everyone shares my distrust of numbers. Many – maybe even most – parents crave specific guidelines for navigating what they see as the mysterious waters of child rearing. "How many ounces should he be gaining each week?" One of the most powerful deterrents to breastfeeding is the fact that the human breast is neither transparent nor etched with milliliter markings. Parents don’t usually deal well with the vagueness of biologic variability.

©Alex Vasilev/Fotolia.com

I am frequently asked, "How many hours should my child be sleeping?" As you might expect, I don’t usually include a number in my answer, but when I was writing "Is My Child Overtired?" (New York: Simon & Schuster, 2000), my editor wouldn’t accept a nonnumerical answer. So with Dr. Richard Ferber’s permission, I included the table from his classic "Solve Your Child’s Sleep Problems" (New York: Simon & Schuster, 1985). But as much as I respect my former classmate’s experience with sleep problems, I have never felt comfortable with the numbers in that table.

My discomfort has recently been reinforced by a special article in Pediatrics (2012;129:548-56). Australian investigators undertook a systematic review of the literature from 1897 to 2009. What they discovered was that each year, "experts" recommended ¾ minute less sleep on average than had been advised the previous year. However, the amount of sleep that children were actually getting was decreasing by almost exactly the same amount. This means that over the last 100 years, experts have consistently recommended 37 more minutes of sleep than children have been getting. Both the recommendation and the reality have decreased over time. During that century, most observers have usually attributed the decline to the stresses of "modern life."

The researchers correctly concluded that, "there is almost no empirical evidence for the optimal sleep duration for children." So, although parents may crave a number or a graph, there is little or no scientific basis for giving them what they want.

However, this vacuum doesn’t mean that we should stop advising parents about sleep duration. The Australian researchers suggested that the "sleep need could be determined by studies of sleep extension and restriction accompanied by monitoring relative outcome variables." And, this is the approach that I found works for me. I begin by helping parents identify one or more symptoms or behaviors that I suspect are related to sleep deprivation (for example, tantrums, night terrors, and/or migraine headaches). Then I suggest to parents that they gradually add more sleep to their child’s day with earlier bedtimes and naps and/or by restructuring the morning routine to allow the child to sleep later. When the target behaviors have decreased to a tolerable level, then "enough is enough."

Unfortunately, explaining to parents the concept of biologic variability and crafting a child-specific plan takes a hell of a lot more time than handing them a graph or table unsupported by the evidence.

But, some parents just can’t accept a nonnumerical recommendation. Whether it is insecurity or an obsessive personality, they aren’t satisfied without rules to govern their parenting. The only time I feel comfortable playing along is when it comes to television viewing. One hour a day is enough. In fact, it’s probably more than enough.

Dr. William Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

I was an art history major in college. The challenge of sorting out ancient Greek sculptures and Renaissance paintings suited my observational skills and avoided my difficulties with numbers. When it came time to practice medicine, it was clear that I would behave more like an artist than a scientist. I have stubbornly resisted requests to attach numbers to things that don’t warrant their specificity.

But, not everyone shares my distrust of numbers. Many – maybe even most – parents crave specific guidelines for navigating what they see as the mysterious waters of child rearing. "How many ounces should he be gaining each week?" One of the most powerful deterrents to breastfeeding is the fact that the human breast is neither transparent nor etched with milliliter markings. Parents don’t usually deal well with the vagueness of biologic variability.

©Alex Vasilev/Fotolia.com

I am frequently asked, "How many hours should my child be sleeping?" As you might expect, I don’t usually include a number in my answer, but when I was writing "Is My Child Overtired?" (New York: Simon & Schuster, 2000), my editor wouldn’t accept a nonnumerical answer. So with Dr. Richard Ferber’s permission, I included the table from his classic "Solve Your Child’s Sleep Problems" (New York: Simon & Schuster, 1985). But as much as I respect my former classmate’s experience with sleep problems, I have never felt comfortable with the numbers in that table.

My discomfort has recently been reinforced by a special article in Pediatrics (2012;129:548-56). Australian investigators undertook a systematic review of the literature from 1897 to 2009. What they discovered was that each year, "experts" recommended ¾ minute less sleep on average than had been advised the previous year. However, the amount of sleep that children were actually getting was decreasing by almost exactly the same amount. This means that over the last 100 years, experts have consistently recommended 37 more minutes of sleep than children have been getting. Both the recommendation and the reality have decreased over time. During that century, most observers have usually attributed the decline to the stresses of "modern life."

The researchers correctly concluded that, "there is almost no empirical evidence for the optimal sleep duration for children." So, although parents may crave a number or a graph, there is little or no scientific basis for giving them what they want.

However, this vacuum doesn’t mean that we should stop advising parents about sleep duration. The Australian researchers suggested that the "sleep need could be determined by studies of sleep extension and restriction accompanied by monitoring relative outcome variables." And, this is the approach that I found works for me. I begin by helping parents identify one or more symptoms or behaviors that I suspect are related to sleep deprivation (for example, tantrums, night terrors, and/or migraine headaches). Then I suggest to parents that they gradually add more sleep to their child’s day with earlier bedtimes and naps and/or by restructuring the morning routine to allow the child to sleep later. When the target behaviors have decreased to a tolerable level, then "enough is enough."

Unfortunately, explaining to parents the concept of biologic variability and crafting a child-specific plan takes a hell of a lot more time than handing them a graph or table unsupported by the evidence.

But, some parents just can’t accept a nonnumerical recommendation. Whether it is insecurity or an obsessive personality, they aren’t satisfied without rules to govern their parenting. The only time I feel comfortable playing along is when it comes to television viewing. One hour a day is enough. In fact, it’s probably more than enough.

Dr. William Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

I was an art history major in college. The challenge of sorting out ancient Greek sculptures and Renaissance paintings suited my observational skills and avoided my difficulties with numbers. When it came time to practice medicine, it was clear that I would behave more like an artist than a scientist. I have stubbornly resisted requests to attach numbers to things that don’t warrant their specificity.

But, not everyone shares my distrust of numbers. Many – maybe even most – parents crave specific guidelines for navigating what they see as the mysterious waters of child rearing. "How many ounces should he be gaining each week?" One of the most powerful deterrents to breastfeeding is the fact that the human breast is neither transparent nor etched with milliliter markings. Parents don’t usually deal well with the vagueness of biologic variability.

©Alex Vasilev/Fotolia.com

I am frequently asked, "How many hours should my child be sleeping?" As you might expect, I don’t usually include a number in my answer, but when I was writing "Is My Child Overtired?" (New York: Simon & Schuster, 2000), my editor wouldn’t accept a nonnumerical answer. So with Dr. Richard Ferber’s permission, I included the table from his classic "Solve Your Child’s Sleep Problems" (New York: Simon & Schuster, 1985). But as much as I respect my former classmate’s experience with sleep problems, I have never felt comfortable with the numbers in that table.

My discomfort has recently been reinforced by a special article in Pediatrics (2012;129:548-56). Australian investigators undertook a systematic review of the literature from 1897 to 2009. What they discovered was that each year, "experts" recommended ¾ minute less sleep on average than had been advised the previous year. However, the amount of sleep that children were actually getting was decreasing by almost exactly the same amount. This means that over the last 100 years, experts have consistently recommended 37 more minutes of sleep than children have been getting. Both the recommendation and the reality have decreased over time. During that century, most observers have usually attributed the decline to the stresses of "modern life."

The researchers correctly concluded that, "there is almost no empirical evidence for the optimal sleep duration for children." So, although parents may crave a number or a graph, there is little or no scientific basis for giving them what they want.

However, this vacuum doesn’t mean that we should stop advising parents about sleep duration. The Australian researchers suggested that the "sleep need could be determined by studies of sleep extension and restriction accompanied by monitoring relative outcome variables." And, this is the approach that I found works for me. I begin by helping parents identify one or more symptoms or behaviors that I suspect are related to sleep deprivation (for example, tantrums, night terrors, and/or migraine headaches). Then I suggest to parents that they gradually add more sleep to their child’s day with earlier bedtimes and naps and/or by restructuring the morning routine to allow the child to sleep later. When the target behaviors have decreased to a tolerable level, then "enough is enough."

Unfortunately, explaining to parents the concept of biologic variability and crafting a child-specific plan takes a hell of a lot more time than handing them a graph or table unsupported by the evidence.

But, some parents just can’t accept a nonnumerical recommendation. Whether it is insecurity or an obsessive personality, they aren’t satisfied without rules to govern their parenting. The only time I feel comfortable playing along is when it comes to television viewing. One hour a day is enough. In fact, it’s probably more than enough.

Dr. William Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

On my first pass through the February 2012 issue of Pediatrics, one title caught my eye. Societal Values and Policies May Curtail Preschool Children’s Physical Activity in Child Care Centers (Pediatrics 2012;129:265-74) screams out the obvious, but its message is one that this country needs to hear and take to heart. One could shorten the title to Societal Values and Policies Curtail Children’s Physical Activity and be correct.

Anyone who has spent any time with young children (or animals for that matter) must notice that given ample space and a variety of objects, the little creatures will stay active until they drop from temporary exhaustion. And, we don’t need two nutritionists and a statistician to remind us that inactivity is one of the key contributors to obesity.

© Orchidpoet/iStockphoto

While Copeland and her coauthors list financial restraints and an emphasis on academics as major contributors to inactivity, it is safety concerns that earn their first star. In their study, day care providers were understandably worried about what might happen if a child was injured while they were in charge. This concern is unfortunately magnified by the litigious nature of our society. But parents also were concerned that their children would be injured during physical activity. Of course, none of us want our children to suffer any harm, but it seems to me that over the last 50 years, this instinctual concern has suffered a tragic metamorphosis and resulted in a paralysis that is eroding the health of our young people and, by extension, the entire population.

In the 1950s, when I was 12 years old, my parents allowed me and a friend to bicycle unaccompanied nearly 200 miles from Pleasantville, N.Y., to Cooperstown. We had no interest in the National Baseball Hall of Fame and Museum, just adventure. I think they underestimated our resolve and figured we would be back home by evening of the first day. But, they let it happen. Today, with cell phones and a GPS, that trip would probably be a much safer excursion. But can you imagine it happening?

Ironically, it is the communication explosion that could be making things safer for children, and it is one of the primary drivers of the protectionist mentality of today’s parents. Every abduction and gory accident becomes national and international news in a matter of seconds. The more gruesome and unusual, the faster it can go viral.

It has always seemed to me that just about everything good or bad can be described by a bell-shaped curve. Of course, horrible accidents and abductions occur in the tail of that curve – they are rare and anomalous. But because parents can hear about them and see them every day on a variety of media, they believe these terrible events are much more likely than they are. The result is that the tail is wagging the dog.

If you want to read how absurd the situation can become, you might want to check out some of the examples cited by Lenore Skenazy, who writes about them on freerangekids.wordpress.com. One school department chose to eliminate voting in school buildings because voters might present a danger to the schoolchildren.

As pediatricians, we can play a role in stemming the tide of unhealthy protective custody by helping parents understand the true frequency of bad events and by balancing our safety messages with a plea to give children time and space to use and explore with their bodies. I fear that sometimes we are overzealous in our safety messages while neglecting the important truths about the value of activity. Exploring with a parent the factors that are preventing his or her child from being active can be time consuming. But it is time well spent. Of course bad stuff will happen if we encourage vigorous play, but restricting it is creating a much worse outcome.

Dr. William Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

On my first pass through the February 2012 issue of Pediatrics, one title caught my eye. Societal Values and Policies May Curtail Preschool Children’s Physical Activity in Child Care Centers (Pediatrics 2012;129:265-74) screams out the obvious, but its message is one that this country needs to hear and take to heart. One could shorten the title to Societal Values and Policies Curtail Children’s Physical Activity and be correct.

Anyone who has spent any time with young children (or animals for that matter) must notice that given ample space and a variety of objects, the little creatures will stay active until they drop from temporary exhaustion. And, we don’t need two nutritionists and a statistician to remind us that inactivity is one of the key contributors to obesity.

© Orchidpoet/iStockphoto

While Copeland and her coauthors list financial restraints and an emphasis on academics as major contributors to inactivity, it is safety concerns that earn their first star. In their study, day care providers were understandably worried about what might happen if a child was injured while they were in charge. This concern is unfortunately magnified by the litigious nature of our society. But parents also were concerned that their children would be injured during physical activity. Of course, none of us want our children to suffer any harm, but it seems to me that over the last 50 years, this instinctual concern has suffered a tragic metamorphosis and resulted in a paralysis that is eroding the health of our young people and, by extension, the entire population.

In the 1950s, when I was 12 years old, my parents allowed me and a friend to bicycle unaccompanied nearly 200 miles from Pleasantville, N.Y., to Cooperstown. We had no interest in the National Baseball Hall of Fame and Museum, just adventure. I think they underestimated our resolve and figured we would be back home by evening of the first day. But, they let it happen. Today, with cell phones and a GPS, that trip would probably be a much safer excursion. But can you imagine it happening?

Ironically, it is the communication explosion that could be making things safer for children, and it is one of the primary drivers of the protectionist mentality of today’s parents. Every abduction and gory accident becomes national and international news in a matter of seconds. The more gruesome and unusual, the faster it can go viral.

It has always seemed to me that just about everything good or bad can be described by a bell-shaped curve. Of course, horrible accidents and abductions occur in the tail of that curve – they are rare and anomalous. But because parents can hear about them and see them every day on a variety of media, they believe these terrible events are much more likely than they are. The result is that the tail is wagging the dog.

If you want to read how absurd the situation can become, you might want to check out some of the examples cited by Lenore Skenazy, who writes about them on freerangekids.wordpress.com. One school department chose to eliminate voting in school buildings because voters might present a danger to the schoolchildren.

As pediatricians, we can play a role in stemming the tide of unhealthy protective custody by helping parents understand the true frequency of bad events and by balancing our safety messages with a plea to give children time and space to use and explore with their bodies. I fear that sometimes we are overzealous in our safety messages while neglecting the important truths about the value of activity. Exploring with a parent the factors that are preventing his or her child from being active can be time consuming. But it is time well spent. Of course bad stuff will happen if we encourage vigorous play, but restricting it is creating a much worse outcome.

Dr. William Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

On my first pass through the February 2012 issue of Pediatrics, one title caught my eye. Societal Values and Policies May Curtail Preschool Children’s Physical Activity in Child Care Centers (Pediatrics 2012;129:265-74) screams out the obvious, but its message is one that this country needs to hear and take to heart. One could shorten the title to Societal Values and Policies Curtail Children’s Physical Activity and be correct.

Anyone who has spent any time with young children (or animals for that matter) must notice that given ample space and a variety of objects, the little creatures will stay active until they drop from temporary exhaustion. And, we don’t need two nutritionists and a statistician to remind us that inactivity is one of the key contributors to obesity.

© Orchidpoet/iStockphoto

While Copeland and her coauthors list financial restraints and an emphasis on academics as major contributors to inactivity, it is safety concerns that earn their first star. In their study, day care providers were understandably worried about what might happen if a child was injured while they were in charge. This concern is unfortunately magnified by the litigious nature of our society. But parents also were concerned that their children would be injured during physical activity. Of course, none of us want our children to suffer any harm, but it seems to me that over the last 50 years, this instinctual concern has suffered a tragic metamorphosis and resulted in a paralysis that is eroding the health of our young people and, by extension, the entire population.

In the 1950s, when I was 12 years old, my parents allowed me and a friend to bicycle unaccompanied nearly 200 miles from Pleasantville, N.Y., to Cooperstown. We had no interest in the National Baseball Hall of Fame and Museum, just adventure. I think they underestimated our resolve and figured we would be back home by evening of the first day. But, they let it happen. Today, with cell phones and a GPS, that trip would probably be a much safer excursion. But can you imagine it happening?

Ironically, it is the communication explosion that could be making things safer for children, and it is one of the primary drivers of the protectionist mentality of today’s parents. Every abduction and gory accident becomes national and international news in a matter of seconds. The more gruesome and unusual, the faster it can go viral.

It has always seemed to me that just about everything good or bad can be described by a bell-shaped curve. Of course, horrible accidents and abductions occur in the tail of that curve – they are rare and anomalous. But because parents can hear about them and see them every day on a variety of media, they believe these terrible events are much more likely than they are. The result is that the tail is wagging the dog.

If you want to read how absurd the situation can become, you might want to check out some of the examples cited by Lenore Skenazy, who writes about them on freerangekids.wordpress.com. One school department chose to eliminate voting in school buildings because voters might present a danger to the schoolchildren.

As pediatricians, we can play a role in stemming the tide of unhealthy protective custody by helping parents understand the true frequency of bad events and by balancing our safety messages with a plea to give children time and space to use and explore with their bodies. I fear that sometimes we are overzealous in our safety messages while neglecting the important truths about the value of activity. Exploring with a parent the factors that are preventing his or her child from being active can be time consuming. But it is time well spent. Of course bad stuff will happen if we encourage vigorous play, but restricting it is creating a much worse outcome.

Dr. William Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

I am a malpractice suit survivor. About 15 years ago, along with two other physicians, I emerged from a challenging 7-year journey that ended with a weeklong jury trial and a unanimous verdict in our favor.

One might assume that as a result of this painful chapter in my life, I am very careful to request lab work and consultations that might have even a remote association with each case I see.

Actually, exactly the opposite is the case. I think this counterintuitive response to my painful experience helped me realize that, from a medical perspective, the initiation of a malpractice suit is often so irrational that no battery of blood tests or imaging studies can protect me. So I might as well continue to practice the best medicine I can and hope for the best. Establishing a sympathetic and caring relationship with patients may help minimize the risk of a suit. But, as in our case, the family of this very premature infant had recently arrived in town and two of us had never met them.

Although I have arrived at a point in my career where I am comfortable practicing very little defensive medicine, I fear I remain in the minority. In a recent study, a team of researchers at Dartmouth Medical School in Hanover, N.H., reported that 42% of the primary care physicians they surveyed felt that patients received too much care (Arch. Intern. Med. 2011:171;1582-5). When asked about the causes of aggressive care, 76% felt that malpractice concern was a contributor. (More than half also felt that clinical performance measures were contributors). Some 83% felt that they could be "easily sued" if they failed to request a usually ordered test. However, only 21% felt that they would be vulnerable if they requested a nonstandard test.

Unfortunately, many of the reports I have seen underestimate the magnitude of the problem because younger physicians may not realize that they are already practicing defensive medicine. The problem has been going on for so many years that today’s graduates have been trained by physicians who themselves were trained by physicians who were probably unaware of the circumstances in which the original unfortunate physician was sued for failing to order a test. Irrational habits that are built on lawsuit fears can become codified just as easily as good habits that are based on good science.

Is there a solution to litigation-stimulated aggressive care? I don’t think telling my "success" story – surviving a malpractice suit with my family, my marriage, and my practice intact – is the answer. Although it may have been a turning point in my life, the take-home message is certainly not "Don’t worry; a malpractice suit isn’t all that bad."

We missed one opportunity when the HMO era came to a crashing end. If well implemented, plans that both reward and defend physicians who practice lean and safe medicine could have gone a long way toward discouraging the malpractice suits of physicians who practice good but not aggressive medicine.

Another missed opportunity occurred when President Obama initially laid out his plans for health care reform. If tort reform on a national scale had been included as one of the cornerstones of the package, a groundswell of support from physicians might have kept up the momentum for a sensible and workable plan. But the ball was fumbled and unfortunately many of us still feel forced to play defense, even though we know it’s not in the best interest of either our patients or our country.

This column, Letters From Maine, appears regularly in Pediatric News, a publication of Elsevier. Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

I am a malpractice suit survivor. About 15 years ago, along with two other physicians, I emerged from a challenging 7-year journey that ended with a weeklong jury trial and a unanimous verdict in our favor.

One might assume that as a result of this painful chapter in my life, I am very careful to request lab work and consultations that might have even a remote association with each case I see.

Actually, exactly the opposite is the case. I think this counterintuitive response to my painful experience helped me realize that, from a medical perspective, the initiation of a malpractice suit is often so irrational that no battery of blood tests or imaging studies can protect me. So I might as well continue to practice the best medicine I can and hope for the best. Establishing a sympathetic and caring relationship with patients may help minimize the risk of a suit. But, as in our case, the family of this very premature infant had recently arrived in town and two of us had never met them.

Although I have arrived at a point in my career where I am comfortable practicing very little defensive medicine, I fear I remain in the minority. In a recent study, a team of researchers at Dartmouth Medical School in Hanover, N.H., reported that 42% of the primary care physicians they surveyed felt that patients received too much care (Arch. Intern. Med. 2011:171;1582-5). When asked about the causes of aggressive care, 76% felt that malpractice concern was a contributor. (More than half also felt that clinical performance measures were contributors). Some 83% felt that they could be "easily sued" if they failed to request a usually ordered test. However, only 21% felt that they would be vulnerable if they requested a nonstandard test.

Unfortunately, many of the reports I have seen underestimate the magnitude of the problem because younger physicians may not realize that they are already practicing defensive medicine. The problem has been going on for so many years that today’s graduates have been trained by physicians who themselves were trained by physicians who were probably unaware of the circumstances in which the original unfortunate physician was sued for failing to order a test. Irrational habits that are built on lawsuit fears can become codified just as easily as good habits that are based on good science.

Is there a solution to litigation-stimulated aggressive care? I don’t think telling my "success" story – surviving a malpractice suit with my family, my marriage, and my practice intact – is the answer. Although it may have been a turning point in my life, the take-home message is certainly not "Don’t worry; a malpractice suit isn’t all that bad."

We missed one opportunity when the HMO era came to a crashing end. If well implemented, plans that both reward and defend physicians who practice lean and safe medicine could have gone a long way toward discouraging the malpractice suits of physicians who practice good but not aggressive medicine.

Another missed opportunity occurred when President Obama initially laid out his plans for health care reform. If tort reform on a national scale had been included as one of the cornerstones of the package, a groundswell of support from physicians might have kept up the momentum for a sensible and workable plan. But the ball was fumbled and unfortunately many of us still feel forced to play defense, even though we know it’s not in the best interest of either our patients or our country.

This column, Letters From Maine, appears regularly in Pediatric News, a publication of Elsevier. Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

I am a malpractice suit survivor. About 15 years ago, along with two other physicians, I emerged from a challenging 7-year journey that ended with a weeklong jury trial and a unanimous verdict in our favor.

One might assume that as a result of this painful chapter in my life, I am very careful to request lab work and consultations that might have even a remote association with each case I see.

Actually, exactly the opposite is the case. I think this counterintuitive response to my painful experience helped me realize that, from a medical perspective, the initiation of a malpractice suit is often so irrational that no battery of blood tests or imaging studies can protect me. So I might as well continue to practice the best medicine I can and hope for the best. Establishing a sympathetic and caring relationship with patients may help minimize the risk of a suit. But, as in our case, the family of this very premature infant had recently arrived in town and two of us had never met them.

Although I have arrived at a point in my career where I am comfortable practicing very little defensive medicine, I fear I remain in the minority. In a recent study, a team of researchers at Dartmouth Medical School in Hanover, N.H., reported that 42% of the primary care physicians they surveyed felt that patients received too much care (Arch. Intern. Med. 2011:171;1582-5). When asked about the causes of aggressive care, 76% felt that malpractice concern was a contributor. (More than half also felt that clinical performance measures were contributors). Some 83% felt that they could be "easily sued" if they failed to request a usually ordered test. However, only 21% felt that they would be vulnerable if they requested a nonstandard test.

Unfortunately, many of the reports I have seen underestimate the magnitude of the problem because younger physicians may not realize that they are already practicing defensive medicine. The problem has been going on for so many years that today’s graduates have been trained by physicians who themselves were trained by physicians who were probably unaware of the circumstances in which the original unfortunate physician was sued for failing to order a test. Irrational habits that are built on lawsuit fears can become codified just as easily as good habits that are based on good science.

Is there a solution to litigation-stimulated aggressive care? I don’t think telling my "success" story – surviving a malpractice suit with my family, my marriage, and my practice intact – is the answer. Although it may have been a turning point in my life, the take-home message is certainly not "Don’t worry; a malpractice suit isn’t all that bad."

We missed one opportunity when the HMO era came to a crashing end. If well implemented, plans that both reward and defend physicians who practice lean and safe medicine could have gone a long way toward discouraging the malpractice suits of physicians who practice good but not aggressive medicine.

Another missed opportunity occurred when President Obama initially laid out his plans for health care reform. If tort reform on a national scale had been included as one of the cornerstones of the package, a groundswell of support from physicians might have kept up the momentum for a sensible and workable plan. But the ball was fumbled and unfortunately many of us still feel forced to play defense, even though we know it’s not in the best interest of either our patients or our country.

This column, Letters From Maine, appears regularly in Pediatric News, a publication of Elsevier. Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

Many years ago I was shocked when some friends told me that when they lived in South America antibiotics could be purchased without a prescription. This seemed dangerous, and at some level, it left me feeling vulnerable. I worried that if this practice ever crept into North America, my status as a professional would be seriously devalued. The mere fact that only physicians could write prescriptions was one of those things that made me special ... certainly more special than lawyers. The power of the prescription pad was one that I felt must be guarded with the utmost diligence.

Things change. For a short while, I struggled with the notion that nurse practitioners could write prescriptions, but I have found that they are no more incautious in their prescribing practices than are physicians. After all, they are trained professionals. But allowing patients to decide when they should use a medication is a leap into another dimension.

But, again things change. When physicians finally realized that in many circumstances otitis media resolves without antibiotics, the door was opened into that uncomfortable dimension.

I can tell a parent, "We probably won’t need to use antibiotics for your child’s ear infection. Call me if she gets sicker." But that isn’t very customer friendly. The parent will need to call back and either make another appointment or wait for the chain of command in my office to spit out a prescription. The first option fails to acknowledge that most parents have jobs, and the second option ties up office overhead that won’t be reimbursed. And what about nights, weekends, holidays, and blizzards?

Another option is to provide the family with a few starter doses of medication to be used if the scenario changes. This is impractical for those of us who no longer accept samples from drug companies.

The solution that seems to work best for me is one I have learned to call a Shared Description Prescription (SDRx). I’m not sure where I first heard the term but I like its message and the way it rolls of the tongue.

I describe (and occasionally write down) the conditions under which I recommend using the medication. The written/printed scrip includes a "Do not fill after" date. I explain that because I can’t predict how things will change, I am asking the parents to be my eyes and ears because they know their child better than anyone else. And, I am sharing the treatment decision with them.

In the 10 years I have been writing SDRxs, most parents have been appropriately cautious in filling them. Those families who are unhappy about the wait-and-see strategy have stopped by the pharmacy on the way home. But they are the same families who would have to return the next day to badger one of my partners into writing a prescription if I hadn’t. Rarely, parents wait longer than I would have to treat, but the delays have not endangered the children.

I have been so pleased with SDRxs that I have expanded their use beyond otitis media. For example: Is the child with unilateral conjunctivitis and a hint of redness and swelling beneath his eye developing preseptal orbital cellulitis? If his parents have a track record as good observers, I will issue an SDRx for antibiotics and arrange for a follow-up call from our office. But I admit the latter doesn’t always happen.

My sense is that my patients are receiving fewer antibiotics. Our computer system only tracks prescriptions that are written, not whether they are filled. Somewhere a computer probably knows that by ever-so-slightly loosening my grip on my prescription pad, I am saving money and combating antibiotic overusage.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected]. This column, "Letters From Maine," appears regularly in Pediatric News, a publication of Elsevier.

Many years ago I was shocked when some friends told me that when they lived in South America antibiotics could be purchased without a prescription. This seemed dangerous, and at some level, it left me feeling vulnerable. I worried that if this practice ever crept into North America, my status as a professional would be seriously devalued. The mere fact that only physicians could write prescriptions was one of those things that made me special ... certainly more special than lawyers. The power of the prescription pad was one that I felt must be guarded with the utmost diligence.

Things change. For a short while, I struggled with the notion that nurse practitioners could write prescriptions, but I have found that they are no more incautious in their prescribing practices than are physicians. After all, they are trained professionals. But allowing patients to decide when they should use a medication is a leap into another dimension.

But, again things change. When physicians finally realized that in many circumstances otitis media resolves without antibiotics, the door was opened into that uncomfortable dimension.

I can tell a parent, "We probably won’t need to use antibiotics for your child’s ear infection. Call me if she gets sicker." But that isn’t very customer friendly. The parent will need to call back and either make another appointment or wait for the chain of command in my office to spit out a prescription. The first option fails to acknowledge that most parents have jobs, and the second option ties up office overhead that won’t be reimbursed. And what about nights, weekends, holidays, and blizzards?

Another option is to provide the family with a few starter doses of medication to be used if the scenario changes. This is impractical for those of us who no longer accept samples from drug companies.

The solution that seems to work best for me is one I have learned to call a Shared Description Prescription (SDRx). I’m not sure where I first heard the term but I like its message and the way it rolls of the tongue.

I describe (and occasionally write down) the conditions under which I recommend using the medication. The written/printed scrip includes a "Do not fill after" date. I explain that because I can’t predict how things will change, I am asking the parents to be my eyes and ears because they know their child better than anyone else. And, I am sharing the treatment decision with them.

In the 10 years I have been writing SDRxs, most parents have been appropriately cautious in filling them. Those families who are unhappy about the wait-and-see strategy have stopped by the pharmacy on the way home. But they are the same families who would have to return the next day to badger one of my partners into writing a prescription if I hadn’t. Rarely, parents wait longer than I would have to treat, but the delays have not endangered the children.

I have been so pleased with SDRxs that I have expanded their use beyond otitis media. For example: Is the child with unilateral conjunctivitis and a hint of redness and swelling beneath his eye developing preseptal orbital cellulitis? If his parents have a track record as good observers, I will issue an SDRx for antibiotics and arrange for a follow-up call from our office. But I admit the latter doesn’t always happen.

My sense is that my patients are receiving fewer antibiotics. Our computer system only tracks prescriptions that are written, not whether they are filled. Somewhere a computer probably knows that by ever-so-slightly loosening my grip on my prescription pad, I am saving money and combating antibiotic overusage.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected]. This column, "Letters From Maine," appears regularly in Pediatric News, a publication of Elsevier.

Many years ago I was shocked when some friends told me that when they lived in South America antibiotics could be purchased without a prescription. This seemed dangerous, and at some level, it left me feeling vulnerable. I worried that if this practice ever crept into North America, my status as a professional would be seriously devalued. The mere fact that only physicians could write prescriptions was one of those things that made me special ... certainly more special than lawyers. The power of the prescription pad was one that I felt must be guarded with the utmost diligence.

Things change. For a short while, I struggled with the notion that nurse practitioners could write prescriptions, but I have found that they are no more incautious in their prescribing practices than are physicians. After all, they are trained professionals. But allowing patients to decide when they should use a medication is a leap into another dimension.

But, again things change. When physicians finally realized that in many circumstances otitis media resolves without antibiotics, the door was opened into that uncomfortable dimension.

I can tell a parent, "We probably won’t need to use antibiotics for your child’s ear infection. Call me if she gets sicker." But that isn’t very customer friendly. The parent will need to call back and either make another appointment or wait for the chain of command in my office to spit out a prescription. The first option fails to acknowledge that most parents have jobs, and the second option ties up office overhead that won’t be reimbursed. And what about nights, weekends, holidays, and blizzards?

Another option is to provide the family with a few starter doses of medication to be used if the scenario changes. This is impractical for those of us who no longer accept samples from drug companies.

The solution that seems to work best for me is one I have learned to call a Shared Description Prescription (SDRx). I’m not sure where I first heard the term but I like its message and the way it rolls of the tongue.

I describe (and occasionally write down) the conditions under which I recommend using the medication. The written/printed scrip includes a "Do not fill after" date. I explain that because I can’t predict how things will change, I am asking the parents to be my eyes and ears because they know their child better than anyone else. And, I am sharing the treatment decision with them.

In the 10 years I have been writing SDRxs, most parents have been appropriately cautious in filling them. Those families who are unhappy about the wait-and-see strategy have stopped by the pharmacy on the way home. But they are the same families who would have to return the next day to badger one of my partners into writing a prescription if I hadn’t. Rarely, parents wait longer than I would have to treat, but the delays have not endangered the children.

I have been so pleased with SDRxs that I have expanded their use beyond otitis media. For example: Is the child with unilateral conjunctivitis and a hint of redness and swelling beneath his eye developing preseptal orbital cellulitis? If his parents have a track record as good observers, I will issue an SDRx for antibiotics and arrange for a follow-up call from our office. But I admit the latter doesn’t always happen.

My sense is that my patients are receiving fewer antibiotics. Our computer system only tracks prescriptions that are written, not whether they are filled. Somewhere a computer probably knows that by ever-so-slightly loosening my grip on my prescription pad, I am saving money and combating antibiotic overusage.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected]. This column, "Letters From Maine," appears regularly in Pediatric News, a publication of Elsevier.

We now have at our disposal a large arsenal of effective and safe vaccines. Unfortunately, getting families who could benefit from these immunizations to accept them continues to be a challenge. I recently read a short news story that got me thinking about where the stumbling blocks to vaccine acceptance lie ("Move to Get Bin Laden Hurt Polio Push," Wall Street Journal online, Dec. 3, 2011).

In what seems to me to be a despicable and ill-conceived effort to capture Osama bin Laden, our own Central Intelligence Agency – through a local doctor in Pakistan – set up a fake hepatitis B immunization program near where bin Laden was suspected to be hiding. According to sources, the CIA hoped that DNA samples could be collected from bin Laden’s family members that would confirm the agency’s suspicions. Inevitably, the mock program became public knowledge. Some families have cited this deception as one of their reasons for refusing the ongoing polio eradication program in that region of Pakistan.

This seems to be a tragic example of the end not justifying the means. When it comes to immunization programs, credibility is the currency for those of us whose job it is to administer the vaccines. I suspect that it will be many years and several generations before this deception is forgotten in this part of Pakistan.

Here in the United States, vaccine refusers seem to cluster into three categories. By far, the smallest includes those parents who have severe needle phobia. Although nobody enjoys watching a child receive an injection, the fear in some parents is so intense that they will go to extremes to avoid bringing their child in for a shot. If I am lucky to discover the underlying phobia, I can usually structure the visit so that the parent can be shielded from the sight and sounds of the procedure.

Also by far, the largest group of vaccine rejecters includes parents who are either sadly misinformed (the MMR-autism tragedy is too painful for me to revisit) or – more likely – uninformed about the need for immunization. It is hard to know exactly where to point a finger for this educational deficit. In some cases, serious complications of a disease may occur so infrequently that it is easy to understand why a parent may not have even third- or fourth-hand experience to motivate them; even a 70-year-old pediatrician might retire without ever having seen a varicella-related fatality.

It may be that when history is taught in school, too little emphasis is given to the role that disease has played in the unfolding of our national heritage. In addition to seeing the monuments, perhaps students who visit the nation’s capital should be taken on a stroll through an 18th-century cemetery. My own children have heard nothing about the fear my parents experienced during the polio outbreaks of the 1950s. And has anyone told students the incredible success story of smallpox eradication? It’s science, and it’s history, and it’s information parents need to make informed decisions about their children’s health. We pediatricians need to update it for them, but we rely on schools to provide the basic knowledge foundation.

The third group of immunization decliners includes the parents whom I consider the most frustrating. They often accept the tenet that immunizations are effective, but – although they are happy to reap the benefits of herd immunity – they don’t want to take even the miniscule risk that comes with any immunization. Some believe that by living a "healthy lifestyle" on the periphery of the herd they can avoid the diseases that the rest of us less-virtuous folks are vulnerable to.

Finally, let’s not forget that the government must maintain its credibility when it comes to vaccines – because it’s not just the Pakistanis who are skeptical about immunizations.

We now have at our disposal a large arsenal of effective and safe vaccines. Unfortunately, getting families who could benefit from these immunizations to accept them continues to be a challenge. I recently read a short news story that got me thinking about where the stumbling blocks to vaccine acceptance lie ("Move to Get Bin Laden Hurt Polio Push," Wall Street Journal online, Dec. 3, 2011).

In what seems to me to be a despicable and ill-conceived effort to capture Osama bin Laden, our own Central Intelligence Agency – through a local doctor in Pakistan – set up a fake hepatitis B immunization program near where bin Laden was suspected to be hiding. According to sources, the CIA hoped that DNA samples could be collected from bin Laden’s family members that would confirm the agency’s suspicions. Inevitably, the mock program became public knowledge. Some families have cited this deception as one of their reasons for refusing the ongoing polio eradication program in that region of Pakistan.

This seems to be a tragic example of the end not justifying the means. When it comes to immunization programs, credibility is the currency for those of us whose job it is to administer the vaccines. I suspect that it will be many years and several generations before this deception is forgotten in this part of Pakistan.

Here in the United States, vaccine refusers seem to cluster into three categories. By far, the smallest includes those parents who have severe needle phobia. Although nobody enjoys watching a child receive an injection, the fear in some parents is so intense that they will go to extremes to avoid bringing their child in for a shot. If I am lucky to discover the underlying phobia, I can usually structure the visit so that the parent can be shielded from the sight and sounds of the procedure.

Also by far, the largest group of vaccine rejecters includes parents who are either sadly misinformed (the MMR-autism tragedy is too painful for me to revisit) or – more likely – uninformed about the need for immunization. It is hard to know exactly where to point a finger for this educational deficit. In some cases, serious complications of a disease may occur so infrequently that it is easy to understand why a parent may not have even third- or fourth-hand experience to motivate them; even a 70-year-old pediatrician might retire without ever having seen a varicella-related fatality.

It may be that when history is taught in school, too little emphasis is given to the role that disease has played in the unfolding of our national heritage. In addition to seeing the monuments, perhaps students who visit the nation’s capital should be taken on a stroll through an 18th-century cemetery. My own children have heard nothing about the fear my parents experienced during the polio outbreaks of the 1950s. And has anyone told students the incredible success story of smallpox eradication? It’s science, and it’s history, and it’s information parents need to make informed decisions about their children’s health. We pediatricians need to update it for them, but we rely on schools to provide the basic knowledge foundation.

The third group of immunization decliners includes the parents whom I consider the most frustrating. They often accept the tenet that immunizations are effective, but – although they are happy to reap the benefits of herd immunity – they don’t want to take even the miniscule risk that comes with any immunization. Some believe that by living a "healthy lifestyle" on the periphery of the herd they can avoid the diseases that the rest of us less-virtuous folks are vulnerable to.

Finally, let’s not forget that the government must maintain its credibility when it comes to vaccines – because it’s not just the Pakistanis who are skeptical about immunizations.

We now have at our disposal a large arsenal of effective and safe vaccines. Unfortunately, getting families who could benefit from these immunizations to accept them continues to be a challenge. I recently read a short news story that got me thinking about where the stumbling blocks to vaccine acceptance lie ("Move to Get Bin Laden Hurt Polio Push," Wall Street Journal online, Dec. 3, 2011).

In what seems to me to be a despicable and ill-conceived effort to capture Osama bin Laden, our own Central Intelligence Agency – through a local doctor in Pakistan – set up a fake hepatitis B immunization program near where bin Laden was suspected to be hiding. According to sources, the CIA hoped that DNA samples could be collected from bin Laden’s family members that would confirm the agency’s suspicions. Inevitably, the mock program became public knowledge. Some families have cited this deception as one of their reasons for refusing the ongoing polio eradication program in that region of Pakistan.

This seems to be a tragic example of the end not justifying the means. When it comes to immunization programs, credibility is the currency for those of us whose job it is to administer the vaccines. I suspect that it will be many years and several generations before this deception is forgotten in this part of Pakistan.

Here in the United States, vaccine refusers seem to cluster into three categories. By far, the smallest includes those parents who have severe needle phobia. Although nobody enjoys watching a child receive an injection, the fear in some parents is so intense that they will go to extremes to avoid bringing their child in for a shot. If I am lucky to discover the underlying phobia, I can usually structure the visit so that the parent can be shielded from the sight and sounds of the procedure.

Also by far, the largest group of vaccine rejecters includes parents who are either sadly misinformed (the MMR-autism tragedy is too painful for me to revisit) or – more likely – uninformed about the need for immunization. It is hard to know exactly where to point a finger for this educational deficit. In some cases, serious complications of a disease may occur so infrequently that it is easy to understand why a parent may not have even third- or fourth-hand experience to motivate them; even a 70-year-old pediatrician might retire without ever having seen a varicella-related fatality.

It may be that when history is taught in school, too little emphasis is given to the role that disease has played in the unfolding of our national heritage. In addition to seeing the monuments, perhaps students who visit the nation’s capital should be taken on a stroll through an 18th-century cemetery. My own children have heard nothing about the fear my parents experienced during the polio outbreaks of the 1950s. And has anyone told students the incredible success story of smallpox eradication? It’s science, and it’s history, and it’s information parents need to make informed decisions about their children’s health. We pediatricians need to update it for them, but we rely on schools to provide the basic knowledge foundation.

The third group of immunization decliners includes the parents whom I consider the most frustrating. They often accept the tenet that immunizations are effective, but – although they are happy to reap the benefits of herd immunity – they don’t want to take even the miniscule risk that comes with any immunization. Some believe that by living a "healthy lifestyle" on the periphery of the herd they can avoid the diseases that the rest of us less-virtuous folks are vulnerable to.

Finally, let’s not forget that the government must maintain its credibility when it comes to vaccines – because it’s not just the Pakistanis who are skeptical about immunizations.