Letters from Maine

Unless you have been under a very large rock lately, you must have felt the buzz vibrating from “Battle Hymn of the Tiger Mom.” This best-selling book (New York: Penguin Press, 2011) by Amy Chua, a Yale University law professor, describes her Chinese-influenced parenting style that demands academic excellence and expects hours of practice with a musical instrument. The book has triggered lively debates: Most of the reaction here in the United States has been negative.

A frequent criticism has been that the Tiger Mom's parenting style leaves little time for play and the creativity it can generate. One of the most often cited examples of Ms. Chua's curmudgeonly style is that she forbids her daughters from participating in sleepovers. Now I admit that I haven't read her book, nor do I plan to, because it doesn't sound like I will find much in it I can agree with.

However, anyone who is in favor of banning sleepovers must have at least one screw properly tightened.

Four decades of professional and parental observations have made it very clear that sleepovers have a serious downside. First, let's talk about the term itself. How can any adult in his or her right mind expect a child spending the night in a strange place with a peer or peers whispering-distance away go to sleep? Even worse is the term “slumber party.” During my residency I nodded off during some very boring dinner parties hosted by well-meaning instructors. But in general, “slumber” and “party” are two words that really don't belong in the same sentence.

It is the rare child who can survive the day following a slumber party without being seriously sleep deprived. Depending on the individual child's stamina and manner of expressing fatigue, the symptoms can run from being simply mildly cranky to being knocked off her feet with a blistering migraine headache. I can recall in the case of my daughters that they were basically nonfunctional for the next 18-24 hours.

It is easy to understand why a Tiger Mom who was expecting a full day of piano practice and algebra exercises from her daughter would be upset. In our house, these days lost to sleep deprivation meant that any family activities we had planned for the rest of the weekend had to be suspended. The alternative was to run the significant risk that we would have a cranky and tearful preteen on our hands.

When I'm offered the chance to comment on sleepovers, I make it clear to parents that I'm not wild about them. But I try to be fair and point out that they must weigh the upside of social interaction with the downside that will depend on how their child reacts to sleep deprivation.

For a child with lingering separation anxiety or nocturnal enuresis, an invitation to a sleepover presents a different and at times uncomfortable dilemma. On one hand, he would desperately like to join his peers in an event he believes will be fun. On the other hand is the worry that he will be embarrassed if his vulnerabilities are exposed. Some of these children have clever and caring parents who can coordinate cover-up strategies with the host family to keep the pull-up secret alive.

Some lucky children can feign disappointment as they report, “My mother is one those evil Tiger Moms and she won't let me do sleepovers or have any fun at all.”

Unless you have been under a very large rock lately, you must have felt the buzz vibrating from “Battle Hymn of the Tiger Mom.” This best-selling book (New York: Penguin Press, 2011) by Amy Chua, a Yale University law professor, describes her Chinese-influenced parenting style that demands academic excellence and expects hours of practice with a musical instrument. The book has triggered lively debates: Most of the reaction here in the United States has been negative.

A frequent criticism has been that the Tiger Mom's parenting style leaves little time for play and the creativity it can generate. One of the most often cited examples of Ms. Chua's curmudgeonly style is that she forbids her daughters from participating in sleepovers. Now I admit that I haven't read her book, nor do I plan to, because it doesn't sound like I will find much in it I can agree with.

However, anyone who is in favor of banning sleepovers must have at least one screw properly tightened.

Four decades of professional and parental observations have made it very clear that sleepovers have a serious downside. First, let's talk about the term itself. How can any adult in his or her right mind expect a child spending the night in a strange place with a peer or peers whispering-distance away go to sleep? Even worse is the term “slumber party.” During my residency I nodded off during some very boring dinner parties hosted by well-meaning instructors. But in general, “slumber” and “party” are two words that really don't belong in the same sentence.

It is the rare child who can survive the day following a slumber party without being seriously sleep deprived. Depending on the individual child's stamina and manner of expressing fatigue, the symptoms can run from being simply mildly cranky to being knocked off her feet with a blistering migraine headache. I can recall in the case of my daughters that they were basically nonfunctional for the next 18-24 hours.

It is easy to understand why a Tiger Mom who was expecting a full day of piano practice and algebra exercises from her daughter would be upset. In our house, these days lost to sleep deprivation meant that any family activities we had planned for the rest of the weekend had to be suspended. The alternative was to run the significant risk that we would have a cranky and tearful preteen on our hands.

When I'm offered the chance to comment on sleepovers, I make it clear to parents that I'm not wild about them. But I try to be fair and point out that they must weigh the upside of social interaction with the downside that will depend on how their child reacts to sleep deprivation.

For a child with lingering separation anxiety or nocturnal enuresis, an invitation to a sleepover presents a different and at times uncomfortable dilemma. On one hand, he would desperately like to join his peers in an event he believes will be fun. On the other hand is the worry that he will be embarrassed if his vulnerabilities are exposed. Some of these children have clever and caring parents who can coordinate cover-up strategies with the host family to keep the pull-up secret alive.

Some lucky children can feign disappointment as they report, “My mother is one those evil Tiger Moms and she won't let me do sleepovers or have any fun at all.”

Unless you have been under a very large rock lately, you must have felt the buzz vibrating from “Battle Hymn of the Tiger Mom.” This best-selling book (New York: Penguin Press, 2011) by Amy Chua, a Yale University law professor, describes her Chinese-influenced parenting style that demands academic excellence and expects hours of practice with a musical instrument. The book has triggered lively debates: Most of the reaction here in the United States has been negative.

A frequent criticism has been that the Tiger Mom's parenting style leaves little time for play and the creativity it can generate. One of the most often cited examples of Ms. Chua's curmudgeonly style is that she forbids her daughters from participating in sleepovers. Now I admit that I haven't read her book, nor do I plan to, because it doesn't sound like I will find much in it I can agree with.

However, anyone who is in favor of banning sleepovers must have at least one screw properly tightened.

Four decades of professional and parental observations have made it very clear that sleepovers have a serious downside. First, let's talk about the term itself. How can any adult in his or her right mind expect a child spending the night in a strange place with a peer or peers whispering-distance away go to sleep? Even worse is the term “slumber party.” During my residency I nodded off during some very boring dinner parties hosted by well-meaning instructors. But in general, “slumber” and “party” are two words that really don't belong in the same sentence.

It is the rare child who can survive the day following a slumber party without being seriously sleep deprived. Depending on the individual child's stamina and manner of expressing fatigue, the symptoms can run from being simply mildly cranky to being knocked off her feet with a blistering migraine headache. I can recall in the case of my daughters that they were basically nonfunctional for the next 18-24 hours.

It is easy to understand why a Tiger Mom who was expecting a full day of piano practice and algebra exercises from her daughter would be upset. In our house, these days lost to sleep deprivation meant that any family activities we had planned for the rest of the weekend had to be suspended. The alternative was to run the significant risk that we would have a cranky and tearful preteen on our hands.

When I'm offered the chance to comment on sleepovers, I make it clear to parents that I'm not wild about them. But I try to be fair and point out that they must weigh the upside of social interaction with the downside that will depend on how their child reacts to sleep deprivation.

For a child with lingering separation anxiety or nocturnal enuresis, an invitation to a sleepover presents a different and at times uncomfortable dilemma. On one hand, he would desperately like to join his peers in an event he believes will be fun. On the other hand is the worry that he will be embarrassed if his vulnerabilities are exposed. Some of these children have clever and caring parents who can coordinate cover-up strategies with the host family to keep the pull-up secret alive.

Some lucky children can feign disappointment as they report, “My mother is one those evil Tiger Moms and she won't let me do sleepovers or have any fun at all.”

I recently surveyed my partners and learned that over the last 5 years, they have lost only two patients to “chronic Lyme disease.” Considering that we've got droves of ticks, we should be proud of that statistic – but when I say “lost,” I'm not referring to mortality. Although we have seen plenty of Lyme disease and one young man ended up in the ICU with heart block, we haven't had any deaths that could be attributed to the disease. The losses I am referring to are patients who found their ways to other physicians and were diagnosed with chronic Lyme disease.

 I know I may be stepping into a hornet's nest with this observation, but I am not convinced that chronic Lyme disease exists as a diagnosable clinical entity. But I haven't read any credible peer-reviewed articles that make me abandon my adherence to the Centers for Disease Control and Prevention's recommendation against long-term antibiotics when Lyme disease is only suspected. We're dealing with an illness that may or may not have a rash and a collection of vague symptoms including joint swelling, low-grade fever, fatigue, and myalgias, so a diagnosis based on examination alone can be difficult. Compound this with the lack of a black-and-white laboratory test for a patient with early symptoms, and it's a disease that can at times seem to be shrouded in a haze of mystery. Fear often stalks where mystery is deepest. Fifteen years ago, when Lyme disease was all the rage in Connecticut and coastal Massachusetts, I was afraid that we had been missing it. We had all the ingredients. Maybe we were calling it something else. But we didn't seem to be having an unusual number of undiagnosed problems. However, once the disease really showed up, it was clear we hadn't been missing any cases. The presentations were protean but there was always something concrete that set us on the right track. The rash (primary or secondary), a single joint, a Bell's palsy … something. Treatment was effective.

What hasn't been easy is that there continue to be, and always will be, patients with vague symptoms of fatigue, headache, general body aches, and mild depression who never seem to rest comfortably in a diagnostic niche. They have none of the specific signs or symptoms of Lyme disease, nor does their lab work suggest it as a diagnosis, nor does any other diagnosis pop into mind.

Unfortunately, these patients may find physicians who not only feel that chronic Lyme disease exists (I grudgingly agree that a post–Lyme disease symptom complex might exist) but also believe that it should be treated with antibiotics. These practitioners also must believe that it is a very common condition, because an uncomfortably high percentage of their patients receive the diagnosis.

Staying engaged with these enigmatic patients can be difficult. They want a diagnosis as much as we want to provide one, but mostly they want to get better. It is difficult to continue to appear confident with the attitude that no diagnosis is a safer alternative to the wrong diagnosis. Heavy doses of reassurance and frequent brainstorming visits in hopes of finding an answer can weaken over time. It's not surprising that many families grow impatient with our efforts and seek other opinions. And it's only natural to feel devalued when this happens to us. The challenge is to channel this emotion into introspection, and to search for a better way to manage similar situations when they occur.

I recently surveyed my partners and learned that over the last 5 years, they have lost only two patients to “chronic Lyme disease.” Considering that we've got droves of ticks, we should be proud of that statistic – but when I say “lost,” I'm not referring to mortality. Although we have seen plenty of Lyme disease and one young man ended up in the ICU with heart block, we haven't had any deaths that could be attributed to the disease. The losses I am referring to are patients who found their ways to other physicians and were diagnosed with chronic Lyme disease.

 I know I may be stepping into a hornet's nest with this observation, but I am not convinced that chronic Lyme disease exists as a diagnosable clinical entity. But I haven't read any credible peer-reviewed articles that make me abandon my adherence to the Centers for Disease Control and Prevention's recommendation against long-term antibiotics when Lyme disease is only suspected. We're dealing with an illness that may or may not have a rash and a collection of vague symptoms including joint swelling, low-grade fever, fatigue, and myalgias, so a diagnosis based on examination alone can be difficult. Compound this with the lack of a black-and-white laboratory test for a patient with early symptoms, and it's a disease that can at times seem to be shrouded in a haze of mystery. Fear often stalks where mystery is deepest. Fifteen years ago, when Lyme disease was all the rage in Connecticut and coastal Massachusetts, I was afraid that we had been missing it. We had all the ingredients. Maybe we were calling it something else. But we didn't seem to be having an unusual number of undiagnosed problems. However, once the disease really showed up, it was clear we hadn't been missing any cases. The presentations were protean but there was always something concrete that set us on the right track. The rash (primary or secondary), a single joint, a Bell's palsy … something. Treatment was effective.

What hasn't been easy is that there continue to be, and always will be, patients with vague symptoms of fatigue, headache, general body aches, and mild depression who never seem to rest comfortably in a diagnostic niche. They have none of the specific signs or symptoms of Lyme disease, nor does their lab work suggest it as a diagnosis, nor does any other diagnosis pop into mind.

Unfortunately, these patients may find physicians who not only feel that chronic Lyme disease exists (I grudgingly agree that a post–Lyme disease symptom complex might exist) but also believe that it should be treated with antibiotics. These practitioners also must believe that it is a very common condition, because an uncomfortably high percentage of their patients receive the diagnosis.

Staying engaged with these enigmatic patients can be difficult. They want a diagnosis as much as we want to provide one, but mostly they want to get better. It is difficult to continue to appear confident with the attitude that no diagnosis is a safer alternative to the wrong diagnosis. Heavy doses of reassurance and frequent brainstorming visits in hopes of finding an answer can weaken over time. It's not surprising that many families grow impatient with our efforts and seek other opinions. And it's only natural to feel devalued when this happens to us. The challenge is to channel this emotion into introspection, and to search for a better way to manage similar situations when they occur.

I recently surveyed my partners and learned that over the last 5 years, they have lost only two patients to “chronic Lyme disease.” Considering that we've got droves of ticks, we should be proud of that statistic – but when I say “lost,” I'm not referring to mortality. Although we have seen plenty of Lyme disease and one young man ended up in the ICU with heart block, we haven't had any deaths that could be attributed to the disease. The losses I am referring to are patients who found their ways to other physicians and were diagnosed with chronic Lyme disease.

 I know I may be stepping into a hornet's nest with this observation, but I am not convinced that chronic Lyme disease exists as a diagnosable clinical entity. But I haven't read any credible peer-reviewed articles that make me abandon my adherence to the Centers for Disease Control and Prevention's recommendation against long-term antibiotics when Lyme disease is only suspected. We're dealing with an illness that may or may not have a rash and a collection of vague symptoms including joint swelling, low-grade fever, fatigue, and myalgias, so a diagnosis based on examination alone can be difficult. Compound this with the lack of a black-and-white laboratory test for a patient with early symptoms, and it's a disease that can at times seem to be shrouded in a haze of mystery. Fear often stalks where mystery is deepest. Fifteen years ago, when Lyme disease was all the rage in Connecticut and coastal Massachusetts, I was afraid that we had been missing it. We had all the ingredients. Maybe we were calling it something else. But we didn't seem to be having an unusual number of undiagnosed problems. However, once the disease really showed up, it was clear we hadn't been missing any cases. The presentations were protean but there was always something concrete that set us on the right track. The rash (primary or secondary), a single joint, a Bell's palsy … something. Treatment was effective.

What hasn't been easy is that there continue to be, and always will be, patients with vague symptoms of fatigue, headache, general body aches, and mild depression who never seem to rest comfortably in a diagnostic niche. They have none of the specific signs or symptoms of Lyme disease, nor does their lab work suggest it as a diagnosis, nor does any other diagnosis pop into mind.

Unfortunately, these patients may find physicians who not only feel that chronic Lyme disease exists (I grudgingly agree that a post–Lyme disease symptom complex might exist) but also believe that it should be treated with antibiotics. These practitioners also must believe that it is a very common condition, because an uncomfortably high percentage of their patients receive the diagnosis.

Staying engaged with these enigmatic patients can be difficult. They want a diagnosis as much as we want to provide one, but mostly they want to get better. It is difficult to continue to appear confident with the attitude that no diagnosis is a safer alternative to the wrong diagnosis. Heavy doses of reassurance and frequent brainstorming visits in hopes of finding an answer can weaken over time. It's not surprising that many families grow impatient with our efforts and seek other opinions. And it's only natural to feel devalued when this happens to us. The challenge is to channel this emotion into introspection, and to search for a better way to manage similar situations when they occur.

The debate continues.

An article by Motoko Rich quotes several authors about the role of parents in the outcome of their children ("Nature? Nurture? Not So Fast ..." New York Times, April 17, 2011).

On one side is Amy Chua, the self-professed Tiger Mother, whose behavior suggests that she feels parents can create rules that will mold their children into productive adults ("Battle Hymn of the Tiger Mother," New York: Penguin Press, 2011). On the other side of the spectrum is an economist, Bryan Caplan, Ph.D., who feels that parent-made rules are irrelevant ("Selfish Reasons to Have More Kids: Why Being a Great Parent is Less Work and More Fun Than You Think," New York: Basic Books, 2011).

Ms. Rich goes on to introduce two more positions that I find more appealing. Judith Rich Harris feels that peers have more influence than parents ("The Nurture Assumption: Why Children Turn Out the Way They Do," New York: The Free Press, 1998). And in "Freakonomics: A Rogue Economist Explores the Hidden Side of Everything" (New York: William Morrow, 2005), Steven D. Levitt and Stephen J. Dubner say, "It isn’t so much a matter of what you do as a parent; it’s who you are."

It is this last quote that agrees most closely with my observations after more than 35 years as a pediatrician and parent. Every argument about nature vs. nurture is really about which is more important. No credible observer would deny that who we become as adults is influenced by both our genetic makeup and the environment in which we matured. For the bulk of my career, physicians, or for that matter anyone else, have had little influence on the genetic side of the equation. As for the nurture side, my interest has been primarily in the roles played by peers and parents.

Two aphorisms characterize my observations about the role of parenting.

The first is "monkey see, monkey do." At all ages, one of our most powerful learning tools is mimicry. Our ability to learn by observation has been hard-wired into our nervous system many branches back on our evolutionary tree. Richard Dawkins, an evolutionary biologist, feels that many of the things we do are the reflection of "memes," which were originally learned by copying our living ancestors and then passed down from generations following a pattern similar to genes, but lacking the physical counterpart of DNA. Trial and error may be more powerful, but mimicry is generally safer.

It may just be semantics, but I disagree with the distinction between who we are and what we do, made by the authors of "Freakonomics." While for short periods of time what we do may not be a reflection of who we are, in a home setting it doesn’t take long for children to see through the veneer of what their parents do in public, and to understand who they really are. Unfortunately, children can model the badness in a parent as easily as they can model the goodness.

The second aphorism is "talk is cheap." Too many parents seem to believe that they can talk their children into a desired behavior. It is really a parent’s behavior and not so much what he or she says that sets the example that a child will model. Even very young children understand the sarcasm in "do as I say, not as I do." But a parent must be around to serve as a model. The problem is that parents have a relatively small window in which to model good behavior before the often more powerful force from peers begins to dilute their influence.

The good news in this nature vs. nurture debate is that none of this is absolute. We all know situations in which children have risen above seemingly insurmountable genetic disadvantages. And we have seen successful adults emerge from environments that seemed to lack positive parental modeling. It’s rare, but it happens. Not every apple rots where it falls. Some are lucky enough to roll into a fertile sun-drenched spot and sprout.

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

The debate continues.

An article by Motoko Rich quotes several authors about the role of parents in the outcome of their children ("Nature? Nurture? Not So Fast ..." New York Times, April 17, 2011).

On one side is Amy Chua, the self-professed Tiger Mother, whose behavior suggests that she feels parents can create rules that will mold their children into productive adults ("Battle Hymn of the Tiger Mother," New York: Penguin Press, 2011). On the other side of the spectrum is an economist, Bryan Caplan, Ph.D., who feels that parent-made rules are irrelevant ("Selfish Reasons to Have More Kids: Why Being a Great Parent is Less Work and More Fun Than You Think," New York: Basic Books, 2011).

Ms. Rich goes on to introduce two more positions that I find more appealing. Judith Rich Harris feels that peers have more influence than parents ("The Nurture Assumption: Why Children Turn Out the Way They Do," New York: The Free Press, 1998). And in "Freakonomics: A Rogue Economist Explores the Hidden Side of Everything" (New York: William Morrow, 2005), Steven D. Levitt and Stephen J. Dubner say, "It isn’t so much a matter of what you do as a parent; it’s who you are."

It is this last quote that agrees most closely with my observations after more than 35 years as a pediatrician and parent. Every argument about nature vs. nurture is really about which is more important. No credible observer would deny that who we become as adults is influenced by both our genetic makeup and the environment in which we matured. For the bulk of my career, physicians, or for that matter anyone else, have had little influence on the genetic side of the equation. As for the nurture side, my interest has been primarily in the roles played by peers and parents.

Two aphorisms characterize my observations about the role of parenting.

The first is "monkey see, monkey do." At all ages, one of our most powerful learning tools is mimicry. Our ability to learn by observation has been hard-wired into our nervous system many branches back on our evolutionary tree. Richard Dawkins, an evolutionary biologist, feels that many of the things we do are the reflection of "memes," which were originally learned by copying our living ancestors and then passed down from generations following a pattern similar to genes, but lacking the physical counterpart of DNA. Trial and error may be more powerful, but mimicry is generally safer.

It may just be semantics, but I disagree with the distinction between who we are and what we do, made by the authors of "Freakonomics." While for short periods of time what we do may not be a reflection of who we are, in a home setting it doesn’t take long for children to see through the veneer of what their parents do in public, and to understand who they really are. Unfortunately, children can model the badness in a parent as easily as they can model the goodness.

The second aphorism is "talk is cheap." Too many parents seem to believe that they can talk their children into a desired behavior. It is really a parent’s behavior and not so much what he or she says that sets the example that a child will model. Even very young children understand the sarcasm in "do as I say, not as I do." But a parent must be around to serve as a model. The problem is that parents have a relatively small window in which to model good behavior before the often more powerful force from peers begins to dilute their influence.

The good news in this nature vs. nurture debate is that none of this is absolute. We all know situations in which children have risen above seemingly insurmountable genetic disadvantages. And we have seen successful adults emerge from environments that seemed to lack positive parental modeling. It’s rare, but it happens. Not every apple rots where it falls. Some are lucky enough to roll into a fertile sun-drenched spot and sprout.

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

The debate continues.

An article by Motoko Rich quotes several authors about the role of parents in the outcome of their children ("Nature? Nurture? Not So Fast ..." New York Times, April 17, 2011).

On one side is Amy Chua, the self-professed Tiger Mother, whose behavior suggests that she feels parents can create rules that will mold their children into productive adults ("Battle Hymn of the Tiger Mother," New York: Penguin Press, 2011). On the other side of the spectrum is an economist, Bryan Caplan, Ph.D., who feels that parent-made rules are irrelevant ("Selfish Reasons to Have More Kids: Why Being a Great Parent is Less Work and More Fun Than You Think," New York: Basic Books, 2011).

Ms. Rich goes on to introduce two more positions that I find more appealing. Judith Rich Harris feels that peers have more influence than parents ("The Nurture Assumption: Why Children Turn Out the Way They Do," New York: The Free Press, 1998). And in "Freakonomics: A Rogue Economist Explores the Hidden Side of Everything" (New York: William Morrow, 2005), Steven D. Levitt and Stephen J. Dubner say, "It isn’t so much a matter of what you do as a parent; it’s who you are."

It is this last quote that agrees most closely with my observations after more than 35 years as a pediatrician and parent. Every argument about nature vs. nurture is really about which is more important. No credible observer would deny that who we become as adults is influenced by both our genetic makeup and the environment in which we matured. For the bulk of my career, physicians, or for that matter anyone else, have had little influence on the genetic side of the equation. As for the nurture side, my interest has been primarily in the roles played by peers and parents.

Two aphorisms characterize my observations about the role of parenting.

The first is "monkey see, monkey do." At all ages, one of our most powerful learning tools is mimicry. Our ability to learn by observation has been hard-wired into our nervous system many branches back on our evolutionary tree. Richard Dawkins, an evolutionary biologist, feels that many of the things we do are the reflection of "memes," which were originally learned by copying our living ancestors and then passed down from generations following a pattern similar to genes, but lacking the physical counterpart of DNA. Trial and error may be more powerful, but mimicry is generally safer.

It may just be semantics, but I disagree with the distinction between who we are and what we do, made by the authors of "Freakonomics." While for short periods of time what we do may not be a reflection of who we are, in a home setting it doesn’t take long for children to see through the veneer of what their parents do in public, and to understand who they really are. Unfortunately, children can model the badness in a parent as easily as they can model the goodness.

The second aphorism is "talk is cheap." Too many parents seem to believe that they can talk their children into a desired behavior. It is really a parent’s behavior and not so much what he or she says that sets the example that a child will model. Even very young children understand the sarcasm in "do as I say, not as I do." But a parent must be around to serve as a model. The problem is that parents have a relatively small window in which to model good behavior before the often more powerful force from peers begins to dilute their influence.

The good news in this nature vs. nurture debate is that none of this is absolute. We all know situations in which children have risen above seemingly insurmountable genetic disadvantages. And we have seen successful adults emerge from environments that seemed to lack positive parental modeling. It’s rare, but it happens. Not every apple rots where it falls. Some are lucky enough to roll into a fertile sun-drenched spot and sprout.

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

Regular readers of this column know that I think a lot about (my wife might say obsess over) the role of sleep in the whole wellness package. I suspect that many parents here in Brunswick believe that regardless of their child's diagnosis, I always will manage to include “more sleep” in my list of therapeutic recommendations. Whether the problem is a sprained ankle or nocturnal leg pains, better sleep habits couldn't hurt.

I have recently stumbled across two new studies that have added more fuel to my fire. The first was a survey of more than 15,000 adolescents by James E. Gangwisch, Ph.D., and his associates in the journal Sleep (2010;33:97-106). These researchers found that adolescents who were depressed had shorter sleep durations and later bedtimes than those who were not depressed. Surprisingly, there seemed to be no difference between the groups when they were asked to report whether they were compliant with their bedtimes. In other words, it appears that simply the parental act of setting a bedtime had some protective effect.

I discovered the second study here in the pages of

I suspect that you aren't surprised by the findings in either of these studies. My mother knew all this stuff already. In fact, anyone who has been observing children for more than a handful of years could have predicted the results. Ben Franklin was right, at least about the early to bed bit. But why isn't the message filtering down to parents?

Are we pediatricians not being vocal enough about the importance of sleep? How much anticipatory guidance do you give parents about sleep? Do you wait for them to raise the issue when they perceive a problem? Do you recommend a bedtime? These studies suggest to me that the benefits of having a parentally mandated bedtime are so substantial that every pediatrician should be including this recommendation at every visit.

We all have participated in the Back to Sleep initiative. Why not a To-Bed-by-Seven campaign aimed at new parents. Although adolescent depression and sub-optimal school performance don't tug at our emotions the way that SIDS does, they are nonetheless problems that affect a larger segment of the pediatric population. And there are scores of other conditions – including obesity, attention-deficit/hyperactivity disorder, and migraine headaches – that have some link to sleep deprivation.

I don't have to tell you that it won't be an easy sell. Societal forces that have nudged children's bedtimes well out of the healthy range are deep and complex. A parent who returns from work after 7 o'clock would like to have some “quality time” with his or her child and share in the bedtime ritual is not going to accept this recommendation happily. It should be our job to point out that there isn't much quality going on when a child is kept up past a healthy hour. However, I may just have to be content when I can get the family to at least set a bedtime – even if I know it is too late. It looks like half a loaf may be better than none at all.

Regular readers of this column know that I think a lot about (my wife might say obsess over) the role of sleep in the whole wellness package. I suspect that many parents here in Brunswick believe that regardless of their child's diagnosis, I always will manage to include “more sleep” in my list of therapeutic recommendations. Whether the problem is a sprained ankle or nocturnal leg pains, better sleep habits couldn't hurt.

I have recently stumbled across two new studies that have added more fuel to my fire. The first was a survey of more than 15,000 adolescents by James E. Gangwisch, Ph.D., and his associates in the journal Sleep (2010;33:97-106). These researchers found that adolescents who were depressed had shorter sleep durations and later bedtimes than those who were not depressed. Surprisingly, there seemed to be no difference between the groups when they were asked to report whether they were compliant with their bedtimes. In other words, it appears that simply the parental act of setting a bedtime had some protective effect.

I discovered the second study here in the pages of

I suspect that you aren't surprised by the findings in either of these studies. My mother knew all this stuff already. In fact, anyone who has been observing children for more than a handful of years could have predicted the results. Ben Franklin was right, at least about the early to bed bit. But why isn't the message filtering down to parents?

Are we pediatricians not being vocal enough about the importance of sleep? How much anticipatory guidance do you give parents about sleep? Do you wait for them to raise the issue when they perceive a problem? Do you recommend a bedtime? These studies suggest to me that the benefits of having a parentally mandated bedtime are so substantial that every pediatrician should be including this recommendation at every visit.

We all have participated in the Back to Sleep initiative. Why not a To-Bed-by-Seven campaign aimed at new parents. Although adolescent depression and sub-optimal school performance don't tug at our emotions the way that SIDS does, they are nonetheless problems that affect a larger segment of the pediatric population. And there are scores of other conditions – including obesity, attention-deficit/hyperactivity disorder, and migraine headaches – that have some link to sleep deprivation.

I don't have to tell you that it won't be an easy sell. Societal forces that have nudged children's bedtimes well out of the healthy range are deep and complex. A parent who returns from work after 7 o'clock would like to have some “quality time” with his or her child and share in the bedtime ritual is not going to accept this recommendation happily. It should be our job to point out that there isn't much quality going on when a child is kept up past a healthy hour. However, I may just have to be content when I can get the family to at least set a bedtime – even if I know it is too late. It looks like half a loaf may be better than none at all.

Regular readers of this column know that I think a lot about (my wife might say obsess over) the role of sleep in the whole wellness package. I suspect that many parents here in Brunswick believe that regardless of their child's diagnosis, I always will manage to include “more sleep” in my list of therapeutic recommendations. Whether the problem is a sprained ankle or nocturnal leg pains, better sleep habits couldn't hurt.

I have recently stumbled across two new studies that have added more fuel to my fire. The first was a survey of more than 15,000 adolescents by James E. Gangwisch, Ph.D., and his associates in the journal Sleep (2010;33:97-106). These researchers found that adolescents who were depressed had shorter sleep durations and later bedtimes than those who were not depressed. Surprisingly, there seemed to be no difference between the groups when they were asked to report whether they were compliant with their bedtimes. In other words, it appears that simply the parental act of setting a bedtime had some protective effect.

I discovered the second study here in the pages of

I suspect that you aren't surprised by the findings in either of these studies. My mother knew all this stuff already. In fact, anyone who has been observing children for more than a handful of years could have predicted the results. Ben Franklin was right, at least about the early to bed bit. But why isn't the message filtering down to parents?

Are we pediatricians not being vocal enough about the importance of sleep? How much anticipatory guidance do you give parents about sleep? Do you wait for them to raise the issue when they perceive a problem? Do you recommend a bedtime? These studies suggest to me that the benefits of having a parentally mandated bedtime are so substantial that every pediatrician should be including this recommendation at every visit.

We all have participated in the Back to Sleep initiative. Why not a To-Bed-by-Seven campaign aimed at new parents. Although adolescent depression and sub-optimal school performance don't tug at our emotions the way that SIDS does, they are nonetheless problems that affect a larger segment of the pediatric population. And there are scores of other conditions – including obesity, attention-deficit/hyperactivity disorder, and migraine headaches – that have some link to sleep deprivation.

I don't have to tell you that it won't be an easy sell. Societal forces that have nudged children's bedtimes well out of the healthy range are deep and complex. A parent who returns from work after 7 o'clock would like to have some “quality time” with his or her child and share in the bedtime ritual is not going to accept this recommendation happily. It should be our job to point out that there isn't much quality going on when a child is kept up past a healthy hour. However, I may just have to be content when I can get the family to at least set a bedtime – even if I know it is too late. It looks like half a loaf may be better than none at all.

What do you call the children and parents that you spend most of your days and some of your nights with? I usually refer to them as patients and their families. This shouldn't surprise you since I am old enough that no one seems embarrassed to ask me if I would like a senior citizen discount. But you may refer to the people you serve as clients, particularly if you consider yourself a provider.

Whether you call them patients or clients, the bottom line is that they are our customers and as such deserve good customer service. Unfortunately, I fear that as a group we physicians don't have a great reputation for providing customer-friendly service. I know of – and have endured myself – waiting room experiences on a par with the tarmac imprisonments for which airlines now must pay hefty fines. Some of us work with receptionists and billing office personnel, who as preschoolers must have bonded with Oscar the Grouch instead of Grover or Bert and Ernie.

The ingredients of bad customer service are obvious to anyone who is on the receiving end. However, while you know when you have gotten good customer service, it might be difficult to dissect out exactly what it was that created that impression. Often, it's simply because the person you were dealing is blessed with a pleasant demeanor inherited from a parent. But good customer service can be learned by those of us who are genetically less fortunate.

For example, L.L. Bean perennially receives several awards for good customer service. This past year they were ranked No. 1 by Bloomberg Businessweek. Good customer service has been built into the culture of their business since it was founded by Leon Bean. The company's willingness to accept and/or replace returned items with little question has spawned amusing and amazing suburban legends (hiking boots with bloody gunshot holes, etc.). The people on the phones are knowledgeable, courteous, and eager to help.

Many of my patients' parents work for the company (as does our son) and so, from time to time, I get a glimpse inside the culture that has created this customer-friendly aura. It isn't rocket science. It is a commitment from the top down that they are not only going to offer a quality product, but they will treat you as they'd like to be treated themselves. Now, no person or system is perfect, but I'll bet you have been the beneficiary of good customer service from L.L. Bean.

Can you say that about the patients who come to your office? Do you really know? Do you ever go into your waiting room? Do you hear what your receptionists and billing people tell your patients? As groups get larger and new offices are built, we are often insulated from the ugliness or just plain callousness that goes on over the phone or when the sliding glass window gets rolled back (I hate those).

Let's assume for the moment that none of us physicians is the cause of bad customer service. But are we enabling or permitting it to persist? Parents and patients might not feel comfortable sharing their bad experiences and complaints with us. They may be intimidated by us as authority figures or they may assume that we don't care and/or can't do anything about a rude receptionist.

As more physicians become employees, it is rare that a practice can claim that “the owner is in the store.” However, abandoning ownership doesn't mean that our patients are no longer our customers. They deserve to be treated as we would like to be treated ourselves, and we must take the lead role in making customer service a top priority.

What do you call the children and parents that you spend most of your days and some of your nights with? I usually refer to them as patients and their families. This shouldn't surprise you since I am old enough that no one seems embarrassed to ask me if I would like a senior citizen discount. But you may refer to the people you serve as clients, particularly if you consider yourself a provider.

Whether you call them patients or clients, the bottom line is that they are our customers and as such deserve good customer service. Unfortunately, I fear that as a group we physicians don't have a great reputation for providing customer-friendly service. I know of – and have endured myself – waiting room experiences on a par with the tarmac imprisonments for which airlines now must pay hefty fines. Some of us work with receptionists and billing office personnel, who as preschoolers must have bonded with Oscar the Grouch instead of Grover or Bert and Ernie.

The ingredients of bad customer service are obvious to anyone who is on the receiving end. However, while you know when you have gotten good customer service, it might be difficult to dissect out exactly what it was that created that impression. Often, it's simply because the person you were dealing is blessed with a pleasant demeanor inherited from a parent. But good customer service can be learned by those of us who are genetically less fortunate.

For example, L.L. Bean perennially receives several awards for good customer service. This past year they were ranked No. 1 by Bloomberg Businessweek. Good customer service has been built into the culture of their business since it was founded by Leon Bean. The company's willingness to accept and/or replace returned items with little question has spawned amusing and amazing suburban legends (hiking boots with bloody gunshot holes, etc.). The people on the phones are knowledgeable, courteous, and eager to help.

Many of my patients' parents work for the company (as does our son) and so, from time to time, I get a glimpse inside the culture that has created this customer-friendly aura. It isn't rocket science. It is a commitment from the top down that they are not only going to offer a quality product, but they will treat you as they'd like to be treated themselves. Now, no person or system is perfect, but I'll bet you have been the beneficiary of good customer service from L.L. Bean.

Can you say that about the patients who come to your office? Do you really know? Do you ever go into your waiting room? Do you hear what your receptionists and billing people tell your patients? As groups get larger and new offices are built, we are often insulated from the ugliness or just plain callousness that goes on over the phone or when the sliding glass window gets rolled back (I hate those).

Let's assume for the moment that none of us physicians is the cause of bad customer service. But are we enabling or permitting it to persist? Parents and patients might not feel comfortable sharing their bad experiences and complaints with us. They may be intimidated by us as authority figures or they may assume that we don't care and/or can't do anything about a rude receptionist.

As more physicians become employees, it is rare that a practice can claim that “the owner is in the store.” However, abandoning ownership doesn't mean that our patients are no longer our customers. They deserve to be treated as we would like to be treated ourselves, and we must take the lead role in making customer service a top priority.

What do you call the children and parents that you spend most of your days and some of your nights with? I usually refer to them as patients and their families. This shouldn't surprise you since I am old enough that no one seems embarrassed to ask me if I would like a senior citizen discount. But you may refer to the people you serve as clients, particularly if you consider yourself a provider.

Whether you call them patients or clients, the bottom line is that they are our customers and as such deserve good customer service. Unfortunately, I fear that as a group we physicians don't have a great reputation for providing customer-friendly service. I know of – and have endured myself – waiting room experiences on a par with the tarmac imprisonments for which airlines now must pay hefty fines. Some of us work with receptionists and billing office personnel, who as preschoolers must have bonded with Oscar the Grouch instead of Grover or Bert and Ernie.

The ingredients of bad customer service are obvious to anyone who is on the receiving end. However, while you know when you have gotten good customer service, it might be difficult to dissect out exactly what it was that created that impression. Often, it's simply because the person you were dealing is blessed with a pleasant demeanor inherited from a parent. But good customer service can be learned by those of us who are genetically less fortunate.

For example, L.L. Bean perennially receives several awards for good customer service. This past year they were ranked No. 1 by Bloomberg Businessweek. Good customer service has been built into the culture of their business since it was founded by Leon Bean. The company's willingness to accept and/or replace returned items with little question has spawned amusing and amazing suburban legends (hiking boots with bloody gunshot holes, etc.). The people on the phones are knowledgeable, courteous, and eager to help.

Many of my patients' parents work for the company (as does our son) and so, from time to time, I get a glimpse inside the culture that has created this customer-friendly aura. It isn't rocket science. It is a commitment from the top down that they are not only going to offer a quality product, but they will treat you as they'd like to be treated themselves. Now, no person or system is perfect, but I'll bet you have been the beneficiary of good customer service from L.L. Bean.

Can you say that about the patients who come to your office? Do you really know? Do you ever go into your waiting room? Do you hear what your receptionists and billing people tell your patients? As groups get larger and new offices are built, we are often insulated from the ugliness or just plain callousness that goes on over the phone or when the sliding glass window gets rolled back (I hate those).

Let's assume for the moment that none of us physicians is the cause of bad customer service. But are we enabling or permitting it to persist? Parents and patients might not feel comfortable sharing their bad experiences and complaints with us. They may be intimidated by us as authority figures or they may assume that we don't care and/or can't do anything about a rude receptionist.

As more physicians become employees, it is rare that a practice can claim that “the owner is in the store.” However, abandoning ownership doesn't mean that our patients are no longer our customers. They deserve to be treated as we would like to be treated ourselves, and we must take the lead role in making customer service a top priority.

“Jared, have I told you that when I played football in high school we wore leather helmets?” Of course I had. For decades I have been telling boys just starting their football careers that I had been a “leatherhead.” Jared is a junior, so I'm sure he'd heard my story at least a couple of times. But he's a nice kid and simply shrugged his strapping shoulders, and looked down at his six-pack abs.

Mostly, I tell the anecdote to watch expression on their parents' faces. The kids already assume I am older than dirt. But I enjoy watching their folks struggle to do a bit of quick math to figure out my age.

In the 1960s plastic football helmets were in regular use, but my high school coach was wise beyond his years and realized that their canvas strap suspension systems similar to those for a construction hard hat were inferior to the 1-inch- to 1½-inch–thick all-leather helmets, which were more absorbent. So Coach passed the plastic headgear down to the scrubs and ordered what must have been one of the last production runs of leather helmets for the varsity.

The equipment wasn't the only thing antique about my football career. By the time I was in college, I had on more than a couple of occasions stood in a huddle next to a teammate who was too fog headed from a hit on the previous play to know his assignment on our simplest running play. If he wobbled to the bench, the odds were high that he would be back in the huddle later in the game.

When I became the new doc on the block, I inherited the job of team physician to a pitifully underperforming high school football team. In that role I know that I sent more than a dozen young men with concussions back into action. Despite clearly having had their bell rung, if they knew who they were, who the opponent was, and had a general sense of the score, they could play. If they failed to meet those skimpy criteria, I sat them out and made sure I talked to their parents to be sure they would be watched closely at home that evening. There was never any discussion of limiting their activity for the next week.

Nowadays, concussion is a hot topic at all levels of sport. And while I tend to be an old school kind of guy, this new emphasis is clearly a change for the good. Maybe the biggest step has been the acceptance by physicians, coaches, players, and parents that loss of consciousness is no longer a requirement for the diagnosis. Maybe it never was for some, but the prevailing notion was “no loss of consciousness, no worry.” The second revelation has been that it's the subsequent concussions that are usually the most damaging.

Media coverage of the cautious and patient management of concussion in high-profile athletes has made it much easier for me to recommend the same approach for my patients … and for them to accept it. When high-paid professionals – tough guys by reputation – are willing to sit out big games until their symptoms clear, the wimp factor evaporates.

Many emergency room physicians still seem to be relying less on good histories and exams and instead ordering needless and potentially dangerous head CTs.

While protocols vary, the ones that I have seen seldom call for imaging studies in a patient with a normal exam and a reliable family.

Preseason baseline testing has become standard in our school department, but postconcussion management continues to remain an area with fuzzy edges. Athletes can have reasons for a headache other than a lingering concussion. Even uninjured teenagers can be drifty by nature. But that's never going to change. This old leatherhead has learned some new tricks and is going to err on the side of sitting out the concussed athlete until the fog is a distant memory.

“Jared, have I told you that when I played football in high school we wore leather helmets?” Of course I had. For decades I have been telling boys just starting their football careers that I had been a “leatherhead.” Jared is a junior, so I'm sure he'd heard my story at least a couple of times. But he's a nice kid and simply shrugged his strapping shoulders, and looked down at his six-pack abs.

Mostly, I tell the anecdote to watch expression on their parents' faces. The kids already assume I am older than dirt. But I enjoy watching their folks struggle to do a bit of quick math to figure out my age.

In the 1960s plastic football helmets were in regular use, but my high school coach was wise beyond his years and realized that their canvas strap suspension systems similar to those for a construction hard hat were inferior to the 1-inch- to 1½-inch–thick all-leather helmets, which were more absorbent. So Coach passed the plastic headgear down to the scrubs and ordered what must have been one of the last production runs of leather helmets for the varsity.

The equipment wasn't the only thing antique about my football career. By the time I was in college, I had on more than a couple of occasions stood in a huddle next to a teammate who was too fog headed from a hit on the previous play to know his assignment on our simplest running play. If he wobbled to the bench, the odds were high that he would be back in the huddle later in the game.

When I became the new doc on the block, I inherited the job of team physician to a pitifully underperforming high school football team. In that role I know that I sent more than a dozen young men with concussions back into action. Despite clearly having had their bell rung, if they knew who they were, who the opponent was, and had a general sense of the score, they could play. If they failed to meet those skimpy criteria, I sat them out and made sure I talked to their parents to be sure they would be watched closely at home that evening. There was never any discussion of limiting their activity for the next week.

Nowadays, concussion is a hot topic at all levels of sport. And while I tend to be an old school kind of guy, this new emphasis is clearly a change for the good. Maybe the biggest step has been the acceptance by physicians, coaches, players, and parents that loss of consciousness is no longer a requirement for the diagnosis. Maybe it never was for some, but the prevailing notion was “no loss of consciousness, no worry.” The second revelation has been that it's the subsequent concussions that are usually the most damaging.

Media coverage of the cautious and patient management of concussion in high-profile athletes has made it much easier for me to recommend the same approach for my patients … and for them to accept it. When high-paid professionals – tough guys by reputation – are willing to sit out big games until their symptoms clear, the wimp factor evaporates.

Many emergency room physicians still seem to be relying less on good histories and exams and instead ordering needless and potentially dangerous head CTs.

While protocols vary, the ones that I have seen seldom call for imaging studies in a patient with a normal exam and a reliable family.

Preseason baseline testing has become standard in our school department, but postconcussion management continues to remain an area with fuzzy edges. Athletes can have reasons for a headache other than a lingering concussion. Even uninjured teenagers can be drifty by nature. But that's never going to change. This old leatherhead has learned some new tricks and is going to err on the side of sitting out the concussed athlete until the fog is a distant memory.

“Jared, have I told you that when I played football in high school we wore leather helmets?” Of course I had. For decades I have been telling boys just starting their football careers that I had been a “leatherhead.” Jared is a junior, so I'm sure he'd heard my story at least a couple of times. But he's a nice kid and simply shrugged his strapping shoulders, and looked down at his six-pack abs.

Mostly, I tell the anecdote to watch expression on their parents' faces. The kids already assume I am older than dirt. But I enjoy watching their folks struggle to do a bit of quick math to figure out my age.

In the 1960s plastic football helmets were in regular use, but my high school coach was wise beyond his years and realized that their canvas strap suspension systems similar to those for a construction hard hat were inferior to the 1-inch- to 1½-inch–thick all-leather helmets, which were more absorbent. So Coach passed the plastic headgear down to the scrubs and ordered what must have been one of the last production runs of leather helmets for the varsity.

The equipment wasn't the only thing antique about my football career. By the time I was in college, I had on more than a couple of occasions stood in a huddle next to a teammate who was too fog headed from a hit on the previous play to know his assignment on our simplest running play. If he wobbled to the bench, the odds were high that he would be back in the huddle later in the game.

When I became the new doc on the block, I inherited the job of team physician to a pitifully underperforming high school football team. In that role I know that I sent more than a dozen young men with concussions back into action. Despite clearly having had their bell rung, if they knew who they were, who the opponent was, and had a general sense of the score, they could play. If they failed to meet those skimpy criteria, I sat them out and made sure I talked to their parents to be sure they would be watched closely at home that evening. There was never any discussion of limiting their activity for the next week.

Nowadays, concussion is a hot topic at all levels of sport. And while I tend to be an old school kind of guy, this new emphasis is clearly a change for the good. Maybe the biggest step has been the acceptance by physicians, coaches, players, and parents that loss of consciousness is no longer a requirement for the diagnosis. Maybe it never was for some, but the prevailing notion was “no loss of consciousness, no worry.” The second revelation has been that it's the subsequent concussions that are usually the most damaging.

Media coverage of the cautious and patient management of concussion in high-profile athletes has made it much easier for me to recommend the same approach for my patients … and for them to accept it. When high-paid professionals – tough guys by reputation – are willing to sit out big games until their symptoms clear, the wimp factor evaporates.

Many emergency room physicians still seem to be relying less on good histories and exams and instead ordering needless and potentially dangerous head CTs.

While protocols vary, the ones that I have seen seldom call for imaging studies in a patient with a normal exam and a reliable family.

Preseason baseline testing has become standard in our school department, but postconcussion management continues to remain an area with fuzzy edges. Athletes can have reasons for a headache other than a lingering concussion. Even uninjured teenagers can be drifty by nature. But that's never going to change. This old leatherhead has learned some new tricks and is going to err on the side of sitting out the concussed athlete until the fog is a distant memory.

One of my partners had just returned from the big city where she attended a continuing medical education session on sleep. She excitedly told me, “You know one group is about to publish something about the relationship between sleep-deprivation and postpartum depression?” I smugly replied, “I hope you weren't surprised by their results.” She knows that I wasn't. For decades it has been clear to me that many women and a few men with “baby blues” (I guess the politically correct term is now “maternity blues”) have gotten into that state in large part because they are sleep deprived.

Unfortunately, this association has up to this point received little or no attention on the scale it deserves. In the American Academy of Pediatrics' recent Clinical Report: Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice (Pediatrics 2010;126[5]:1032-9), the word “sleep” appears only once and that is in a laundry list of preventive health that includes the Back to Sleep program. This exhaustive report does include some concerning statistics about the scope of the problem, and the associations between postpartum depression and numerous pediatric developmental and mental health issues.

The report offers an abundance of strategies for helping pediatricians identify and then refer parents with postpartum depression. However, there is no mention of “prevention” of postpartum depression in the report. If I and the researchers who are investigating the association between sleep deprivation and postpartum depression are correct, at least some (and probably many) cases are preventable, and pediatricians can and should play a role.

At prenatal classes and office visits, the issue of sleep hygiene must be on the agenda. Parents-to-be may have heard from other parents that they won't be getting much sleep. But they need to hear it again, and need to hear from the pediatrician some concrete suggestions about how to minimize the impact of sleep deprivation. Immediate postpartum plans for visitors, activities, and travel need to be reality tested. Strategies for using phone answering systems and social networking Web sites to discourage inconsiderate visitors during those first critical days when new parents are exhausted and breastfeeding is on its first wobbly legs should be offered. Empowering a new father to tell visitors, “The pediatrician says Mom and baby really need to be sleeping if the breastfeeding is going to work. Can you come back at another time? You can check our blog for feeding updates and pictures.”

Does the family have a good plan for a support system that includes knowledgeable advisers who are available 24/7? What will be the pediatrician's role on that team? Is the first office visit appropriately timed? In 3 days breastfeeding can crash, and parents can be exhausted beyond repair.

The AAP Clinical Report cites at least one study that refers to an association between not breastfeeding and early cessation of breastfeeding. In my experience, this can be one of those chicken-egg-chicken associations. A sleep-deprived woman will often experience problems with breastfeeding, and a woman who is having trouble breastfeeding can become sleep deprived. Sometimes the solution is to have someone come into the home to relieve the family of other responsibilities. Knowledgeable breastfeeding advisers who are sensitive to a mother's sleep needs can rescue the situation.

There is a fine art of determining when it is time to get an exhausted (and potentially depressed) mother some sleep by offering some formula. If done well, breastfeeding can be saved and depression prevented. If breastfeeding finally crashes, pediatricians must be aware that this can trigger depression, and they must become chameleonic advocates of good nutrition in general, not just advocates of breastfeeding.

At every visit, parents should be asked not only how their child is sleeping, but how they themselves are sleeping. Red flag answers must be dealt with on the spot with sound advice and timely follow-up both by phone and face to face.

The AAP Clinical Report refers to a survey in which pediatricians felt that they lacked sufficient training to diagnose and treat maternal depression. I know that's how I feel. But I certainly can suspect and refer. But more importantly, there is a lot I can do to prevent. When all is said and done, prevention is the pediatrician's mantra.

One of my partners had just returned from the big city where she attended a continuing medical education session on sleep. She excitedly told me, “You know one group is about to publish something about the relationship between sleep-deprivation and postpartum depression?” I smugly replied, “I hope you weren't surprised by their results.” She knows that I wasn't. For decades it has been clear to me that many women and a few men with “baby blues” (I guess the politically correct term is now “maternity blues”) have gotten into that state in large part because they are sleep deprived.

Unfortunately, this association has up to this point received little or no attention on the scale it deserves. In the American Academy of Pediatrics' recent Clinical Report: Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice (Pediatrics 2010;126[5]:1032-9), the word “sleep” appears only once and that is in a laundry list of preventive health that includes the Back to Sleep program. This exhaustive report does include some concerning statistics about the scope of the problem, and the associations between postpartum depression and numerous pediatric developmental and mental health issues.

The report offers an abundance of strategies for helping pediatricians identify and then refer parents with postpartum depression. However, there is no mention of “prevention” of postpartum depression in the report. If I and the researchers who are investigating the association between sleep deprivation and postpartum depression are correct, at least some (and probably many) cases are preventable, and pediatricians can and should play a role.

At prenatal classes and office visits, the issue of sleep hygiene must be on the agenda. Parents-to-be may have heard from other parents that they won't be getting much sleep. But they need to hear it again, and need to hear from the pediatrician some concrete suggestions about how to minimize the impact of sleep deprivation. Immediate postpartum plans for visitors, activities, and travel need to be reality tested. Strategies for using phone answering systems and social networking Web sites to discourage inconsiderate visitors during those first critical days when new parents are exhausted and breastfeeding is on its first wobbly legs should be offered. Empowering a new father to tell visitors, “The pediatrician says Mom and baby really need to be sleeping if the breastfeeding is going to work. Can you come back at another time? You can check our blog for feeding updates and pictures.”

Does the family have a good plan for a support system that includes knowledgeable advisers who are available 24/7? What will be the pediatrician's role on that team? Is the first office visit appropriately timed? In 3 days breastfeeding can crash, and parents can be exhausted beyond repair.

The AAP Clinical Report cites at least one study that refers to an association between not breastfeeding and early cessation of breastfeeding. In my experience, this can be one of those chicken-egg-chicken associations. A sleep-deprived woman will often experience problems with breastfeeding, and a woman who is having trouble breastfeeding can become sleep deprived. Sometimes the solution is to have someone come into the home to relieve the family of other responsibilities. Knowledgeable breastfeeding advisers who are sensitive to a mother's sleep needs can rescue the situation.

There is a fine art of determining when it is time to get an exhausted (and potentially depressed) mother some sleep by offering some formula. If done well, breastfeeding can be saved and depression prevented. If breastfeeding finally crashes, pediatricians must be aware that this can trigger depression, and they must become chameleonic advocates of good nutrition in general, not just advocates of breastfeeding.

At every visit, parents should be asked not only how their child is sleeping, but how they themselves are sleeping. Red flag answers must be dealt with on the spot with sound advice and timely follow-up both by phone and face to face.

The AAP Clinical Report refers to a survey in which pediatricians felt that they lacked sufficient training to diagnose and treat maternal depression. I know that's how I feel. But I certainly can suspect and refer. But more importantly, there is a lot I can do to prevent. When all is said and done, prevention is the pediatrician's mantra.

One of my partners had just returned from the big city where she attended a continuing medical education session on sleep. She excitedly told me, “You know one group is about to publish something about the relationship between sleep-deprivation and postpartum depression?” I smugly replied, “I hope you weren't surprised by their results.” She knows that I wasn't. For decades it has been clear to me that many women and a few men with “baby blues” (I guess the politically correct term is now “maternity blues”) have gotten into that state in large part because they are sleep deprived.

Unfortunately, this association has up to this point received little or no attention on the scale it deserves. In the American Academy of Pediatrics' recent Clinical Report: Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice (Pediatrics 2010;126[5]:1032-9), the word “sleep” appears only once and that is in a laundry list of preventive health that includes the Back to Sleep program. This exhaustive report does include some concerning statistics about the scope of the problem, and the associations between postpartum depression and numerous pediatric developmental and mental health issues.

The report offers an abundance of strategies for helping pediatricians identify and then refer parents with postpartum depression. However, there is no mention of “prevention” of postpartum depression in the report. If I and the researchers who are investigating the association between sleep deprivation and postpartum depression are correct, at least some (and probably many) cases are preventable, and pediatricians can and should play a role.

At prenatal classes and office visits, the issue of sleep hygiene must be on the agenda. Parents-to-be may have heard from other parents that they won't be getting much sleep. But they need to hear it again, and need to hear from the pediatrician some concrete suggestions about how to minimize the impact of sleep deprivation. Immediate postpartum plans for visitors, activities, and travel need to be reality tested. Strategies for using phone answering systems and social networking Web sites to discourage inconsiderate visitors during those first critical days when new parents are exhausted and breastfeeding is on its first wobbly legs should be offered. Empowering a new father to tell visitors, “The pediatrician says Mom and baby really need to be sleeping if the breastfeeding is going to work. Can you come back at another time? You can check our blog for feeding updates and pictures.”

Does the family have a good plan for a support system that includes knowledgeable advisers who are available 24/7? What will be the pediatrician's role on that team? Is the first office visit appropriately timed? In 3 days breastfeeding can crash, and parents can be exhausted beyond repair.

The AAP Clinical Report cites at least one study that refers to an association between not breastfeeding and early cessation of breastfeeding. In my experience, this can be one of those chicken-egg-chicken associations. A sleep-deprived woman will often experience problems with breastfeeding, and a woman who is having trouble breastfeeding can become sleep deprived. Sometimes the solution is to have someone come into the home to relieve the family of other responsibilities. Knowledgeable breastfeeding advisers who are sensitive to a mother's sleep needs can rescue the situation.

There is a fine art of determining when it is time to get an exhausted (and potentially depressed) mother some sleep by offering some formula. If done well, breastfeeding can be saved and depression prevented. If breastfeeding finally crashes, pediatricians must be aware that this can trigger depression, and they must become chameleonic advocates of good nutrition in general, not just advocates of breastfeeding.

At every visit, parents should be asked not only how their child is sleeping, but how they themselves are sleeping. Red flag answers must be dealt with on the spot with sound advice and timely follow-up both by phone and face to face.

The AAP Clinical Report refers to a survey in which pediatricians felt that they lacked sufficient training to diagnose and treat maternal depression. I know that's how I feel. But I certainly can suspect and refer. But more importantly, there is a lot I can do to prevent. When all is said and done, prevention is the pediatrician's mantra.

“Isn't it boring seeing all those snotty-nosed kids?”

This isn't the first time I've heard this question from one of my colleagues who wouldn't think of laying his stethoscope on anyone under the age of 25. My usual response is, “How can you tolerate a whole day of listening to whining adults?” I guess after awhile one just accepts the potholes in the path one has chosen.

For me, snotty noses aren't just slimy annoyances that I have learned to tolerate. I have actually come to appreciate and even embrace the reality of snot in all its multicolored drippiness. The fact that snot was probably not a word you encountered in medical school is a bit odd, because snot is the very substance that lubricates the wheels of general pediatrics. Without snot, your accounts receivable would grind to a bankrupting halt.

If noses didn't run, a parent might not know his child's cold had lasted for 3 weeks. How many of the children with allergic rhinitis would sit in your office saluting each other across the waiting room if their noses were dry?

I have been immersed in snot since the day I chose to practice pediatrics. It's the reason why between patients sometimes I must scrub up to my elbows like a surgeon. Snot is what I polish off my glasses at the end of a busy morning.

But not everyone seems to understand and appreciate the variety of liquids that can run out of a youngster's nose. For example, too few people appreciate the counterintuitive fact that for the most part the color of snot is not one of Mother Nature's warning signs of severe illness. I try to appear to be listening patiently as parents struggle to choose just the right shade and consistency to describe their child's runny nose. I always end up blurting out, “You know, color doesn't really tell me much; let me hear some more about his other symptoms.” I have struggled mightily to get day care providers to expunge the words “colored nasal mucus” from their lists of exclusionary conditions. But, sometimes I feel as if I am swimming up stream, so to speak.

I continue to be surprised and disappointed at the number of physicians who diagnose and treat “sinusitis” in situations in which the child's only sign or symptom seems to have been off-color mucus. Once a child has been labeled as sinusitis prone, I have a devil of a time convincing his parents that an antibiotic isn't the best choice every time he has a yucky-looking runny nose.

I have even more trouble convincing parents to stop wiping their child's nose every time they see it dripping. By the end of the day, the poor little tyke's nostrils and upper lip look like raw hamburger. It seems to be a blow against motherhood to just let the snot cake up and then gently soak it off before naps and bedtimes. I know it's not a pretty picture, but it's the right thing to do.

While it may not qualify as snot, the foul-smelling unilateral runny nose that usually accompanies a retained foreign body has provided me with numerous rewarding diagnostic and therapeutic successes. Extracting a rank piece of foam rubber from the nose of 2-year-old is on a par with deftly removing a cerumen plug the size of a pencil eraser with a single swipe of an ear curette.

If I still haven't convinced you to view snot in the same positive light that I do, how about this: In a recent issue of the New York Times, there was a report suggesting that a runny nose is a sign of a strong and functioning immune system. It turns out the rhinovirus and its cousins create little or no damage to nasal mucosa. Snot is simply a drippy sign that our defenses are revved up and working. Snotty noses are going to be around as long as there are little children. Learn to embrace them.

“Isn't it boring seeing all those snotty-nosed kids?”

This isn't the first time I've heard this question from one of my colleagues who wouldn't think of laying his stethoscope on anyone under the age of 25. My usual response is, “How can you tolerate a whole day of listening to whining adults?” I guess after awhile one just accepts the potholes in the path one has chosen.

For me, snotty noses aren't just slimy annoyances that I have learned to tolerate. I have actually come to appreciate and even embrace the reality of snot in all its multicolored drippiness. The fact that snot was probably not a word you encountered in medical school is a bit odd, because snot is the very substance that lubricates the wheels of general pediatrics. Without snot, your accounts receivable would grind to a bankrupting halt.

If noses didn't run, a parent might not know his child's cold had lasted for 3 weeks. How many of the children with allergic rhinitis would sit in your office saluting each other across the waiting room if their noses were dry?

I have been immersed in snot since the day I chose to practice pediatrics. It's the reason why between patients sometimes I must scrub up to my elbows like a surgeon. Snot is what I polish off my glasses at the end of a busy morning.

But not everyone seems to understand and appreciate the variety of liquids that can run out of a youngster's nose. For example, too few people appreciate the counterintuitive fact that for the most part the color of snot is not one of Mother Nature's warning signs of severe illness. I try to appear to be listening patiently as parents struggle to choose just the right shade and consistency to describe their child's runny nose. I always end up blurting out, “You know, color doesn't really tell me much; let me hear some more about his other symptoms.” I have struggled mightily to get day care providers to expunge the words “colored nasal mucus” from their lists of exclusionary conditions. But, sometimes I feel as if I am swimming up stream, so to speak.

I continue to be surprised and disappointed at the number of physicians who diagnose and treat “sinusitis” in situations in which the child's only sign or symptom seems to have been off-color mucus. Once a child has been labeled as sinusitis prone, I have a devil of a time convincing his parents that an antibiotic isn't the best choice every time he has a yucky-looking runny nose.

I have even more trouble convincing parents to stop wiping their child's nose every time they see it dripping. By the end of the day, the poor little tyke's nostrils and upper lip look like raw hamburger. It seems to be a blow against motherhood to just let the snot cake up and then gently soak it off before naps and bedtimes. I know it's not a pretty picture, but it's the right thing to do.

While it may not qualify as snot, the foul-smelling unilateral runny nose that usually accompanies a retained foreign body has provided me with numerous rewarding diagnostic and therapeutic successes. Extracting a rank piece of foam rubber from the nose of 2-year-old is on a par with deftly removing a cerumen plug the size of a pencil eraser with a single swipe of an ear curette.

If I still haven't convinced you to view snot in the same positive light that I do, how about this: In a recent issue of the New York Times, there was a report suggesting that a runny nose is a sign of a strong and functioning immune system. It turns out the rhinovirus and its cousins create little or no damage to nasal mucosa. Snot is simply a drippy sign that our defenses are revved up and working. Snotty noses are going to be around as long as there are little children. Learn to embrace them.

“Isn't it boring seeing all those snotty-nosed kids?”

This isn't the first time I've heard this question from one of my colleagues who wouldn't think of laying his stethoscope on anyone under the age of 25. My usual response is, “How can you tolerate a whole day of listening to whining adults?” I guess after awhile one just accepts the potholes in the path one has chosen.

For me, snotty noses aren't just slimy annoyances that I have learned to tolerate. I have actually come to appreciate and even embrace the reality of snot in all its multicolored drippiness. The fact that snot was probably not a word you encountered in medical school is a bit odd, because snot is the very substance that lubricates the wheels of general pediatrics. Without snot, your accounts receivable would grind to a bankrupting halt.

If noses didn't run, a parent might not know his child's cold had lasted for 3 weeks. How many of the children with allergic rhinitis would sit in your office saluting each other across the waiting room if their noses were dry?

I have been immersed in snot since the day I chose to practice pediatrics. It's the reason why between patients sometimes I must scrub up to my elbows like a surgeon. Snot is what I polish off my glasses at the end of a busy morning.

But not everyone seems to understand and appreciate the variety of liquids that can run out of a youngster's nose. For example, too few people appreciate the counterintuitive fact that for the most part the color of snot is not one of Mother Nature's warning signs of severe illness. I try to appear to be listening patiently as parents struggle to choose just the right shade and consistency to describe their child's runny nose. I always end up blurting out, “You know, color doesn't really tell me much; let me hear some more about his other symptoms.” I have struggled mightily to get day care providers to expunge the words “colored nasal mucus” from their lists of exclusionary conditions. But, sometimes I feel as if I am swimming up stream, so to speak.

I continue to be surprised and disappointed at the number of physicians who diagnose and treat “sinusitis” in situations in which the child's only sign or symptom seems to have been off-color mucus. Once a child has been labeled as sinusitis prone, I have a devil of a time convincing his parents that an antibiotic isn't the best choice every time he has a yucky-looking runny nose.

I have even more trouble convincing parents to stop wiping their child's nose every time they see it dripping. By the end of the day, the poor little tyke's nostrils and upper lip look like raw hamburger. It seems to be a blow against motherhood to just let the snot cake up and then gently soak it off before naps and bedtimes. I know it's not a pretty picture, but it's the right thing to do.

While it may not qualify as snot, the foul-smelling unilateral runny nose that usually accompanies a retained foreign body has provided me with numerous rewarding diagnostic and therapeutic successes. Extracting a rank piece of foam rubber from the nose of 2-year-old is on a par with deftly removing a cerumen plug the size of a pencil eraser with a single swipe of an ear curette.

If I still haven't convinced you to view snot in the same positive light that I do, how about this: In a recent issue of the New York Times, there was a report suggesting that a runny nose is a sign of a strong and functioning immune system. It turns out the rhinovirus and its cousins create little or no damage to nasal mucosa. Snot is simply a drippy sign that our defenses are revved up and working. Snotty noses are going to be around as long as there are little children. Learn to embrace them.

[email protected]

“Sarah, your son is doing very well. It looks like you are enjoying being a mother. Unless you are having trouble I won't be seeing you until Clay's 4-month visit. I know you said at the last visit that you had your day care plans in order. Are they still solid?”

“Well … Dr. Wilkoff, being a mother has been much more fun than I expected. It is going to be very hard for me to go back to work and leave Clay with someone else. I've enjoyed nursing and although the schedule that my boss has agreed to should allow me to keep nursing, I just don't want to look back a year or 2 from now and regret having missed this special time.

“I never guessed that it would be like this. I enjoy my job. I never ever considered not going back to it. Jason and I have talked and looked at the numbers. He says he's pretty sure we can make it on one income, and he thinks we should try it with me staying home. But I don't know. I'm worried we won't make it, and I don't want to have to ask our parents for help. What do you think, Dr. Wilkoff?”

I have stood at these crossroads that Sarah and Jason are facing dozens of times in my career. Usually, I am an interested, but mute bystander. But, every now and then I will be asked for my 2 cents.

Obviously, it's difficult to give advice without knowing the details of a young family's finances. Because in the end it is all about the money. Are they already living in a house with a mortgage that gobbles up too much of their incomes? Do they have other debt? Whose job is helping fund their health insurance?

But actually it isn't all about the money. It's about some important intangibles. How creative can this young couple be in cutting their expenses? Can they think far enough outside the box to get by with just one vehicle and no cable television? Will Jason have enough stamina to work more hours or find a part-time job? It sounds as though he is committed to the concept of Sarah's staying home. His positive attitude alone suggests to me that this experiment is going to work.

Will Sarah have the stamina after a full day of mothering to work a few hours in the evening a couple of hours a week? Can she accept a part-time job that is well beneath her training and experience?

Even if they can make the new numbers work, will Sarah find a peer group that will support her decision to stay home? Thirty years ago I wouldn't have thought to consider this question. But over the decades I have spoken to enough young mothers who have stayed home to hear that it can feel lonely at times without other women who share their perspective on the frustrations, fears, and successes of parenting.

If Sarah decides to quit her job and stay home, depending on her neighborhood, she will find herself in a small minority, maybe even alone. Will she find enough support to balance what she might perceive as a loss of status associated with stepping away from her career? I may be able to help by reminding her at each visit of the “firsts” she has witnessed by staying at home. And the control she has over things like Clay's sleep schedule and TV exposure.

So what did I tell Sarah today? First, I reminded her that past performance is no guarantee of success, but that whenever family members have shared with me their concerns about this kind of decision it has always worked out. It's not easy swimming against the societal norm, but I had a strong feeling that Sarah and Jason and Clay were going to make it work.

In the interest of gender equality, I must add that the arrangement can work well when the father is the parent who stays home.

[email protected]

“Sarah, your son is doing very well. It looks like you are enjoying being a mother. Unless you are having trouble I won't be seeing you until Clay's 4-month visit. I know you said at the last visit that you had your day care plans in order. Are they still solid?”

“Well … Dr. Wilkoff, being a mother has been much more fun than I expected. It is going to be very hard for me to go back to work and leave Clay with someone else. I've enjoyed nursing and although the schedule that my boss has agreed to should allow me to keep nursing, I just don't want to look back a year or 2 from now and regret having missed this special time.

“I never guessed that it would be like this. I enjoy my job. I never ever considered not going back to it. Jason and I have talked and looked at the numbers. He says he's pretty sure we can make it on one income, and he thinks we should try it with me staying home. But I don't know. I'm worried we won't make it, and I don't want to have to ask our parents for help. What do you think, Dr. Wilkoff?”

I have stood at these crossroads that Sarah and Jason are facing dozens of times in my career. Usually, I am an interested, but mute bystander. But, every now and then I will be asked for my 2 cents.

Obviously, it's difficult to give advice without knowing the details of a young family's finances. Because in the end it is all about the money. Are they already living in a house with a mortgage that gobbles up too much of their incomes? Do they have other debt? Whose job is helping fund their health insurance?

But actually it isn't all about the money. It's about some important intangibles. How creative can this young couple be in cutting their expenses? Can they think far enough outside the box to get by with just one vehicle and no cable television? Will Jason have enough stamina to work more hours or find a part-time job? It sounds as though he is committed to the concept of Sarah's staying home. His positive attitude alone suggests to me that this experiment is going to work.

Will Sarah have the stamina after a full day of mothering to work a few hours in the evening a couple of hours a week? Can she accept a part-time job that is well beneath her training and experience?

Even if they can make the new numbers work, will Sarah find a peer group that will support her decision to stay home? Thirty years ago I wouldn't have thought to consider this question. But over the decades I have spoken to enough young mothers who have stayed home to hear that it can feel lonely at times without other women who share their perspective on the frustrations, fears, and successes of parenting.

If Sarah decides to quit her job and stay home, depending on her neighborhood, she will find herself in a small minority, maybe even alone. Will she find enough support to balance what she might perceive as a loss of status associated with stepping away from her career? I may be able to help by reminding her at each visit of the “firsts” she has witnessed by staying at home. And the control she has over things like Clay's sleep schedule and TV exposure.

So what did I tell Sarah today? First, I reminded her that past performance is no guarantee of success, but that whenever family members have shared with me their concerns about this kind of decision it has always worked out. It's not easy swimming against the societal norm, but I had a strong feeling that Sarah and Jason and Clay were going to make it work.

In the interest of gender equality, I must add that the arrangement can work well when the father is the parent who stays home.

[email protected]

“Sarah, your son is doing very well. It looks like you are enjoying being a mother. Unless you are having trouble I won't be seeing you until Clay's 4-month visit. I know you said at the last visit that you had your day care plans in order. Are they still solid?”

“Well … Dr. Wilkoff, being a mother has been much more fun than I expected. It is going to be very hard for me to go back to work and leave Clay with someone else. I've enjoyed nursing and although the schedule that my boss has agreed to should allow me to keep nursing, I just don't want to look back a year or 2 from now and regret having missed this special time.

“I never guessed that it would be like this. I enjoy my job. I never ever considered not going back to it. Jason and I have talked and looked at the numbers. He says he's pretty sure we can make it on one income, and he thinks we should try it with me staying home. But I don't know. I'm worried we won't make it, and I don't want to have to ask our parents for help. What do you think, Dr. Wilkoff?”

I have stood at these crossroads that Sarah and Jason are facing dozens of times in my career. Usually, I am an interested, but mute bystander. But, every now and then I will be asked for my 2 cents.

Obviously, it's difficult to give advice without knowing the details of a young family's finances. Because in the end it is all about the money. Are they already living in a house with a mortgage that gobbles up too much of their incomes? Do they have other debt? Whose job is helping fund their health insurance?

But actually it isn't all about the money. It's about some important intangibles. How creative can this young couple be in cutting their expenses? Can they think far enough outside the box to get by with just one vehicle and no cable television? Will Jason have enough stamina to work more hours or find a part-time job? It sounds as though he is committed to the concept of Sarah's staying home. His positive attitude alone suggests to me that this experiment is going to work.

Will Sarah have the stamina after a full day of mothering to work a few hours in the evening a couple of hours a week? Can she accept a part-time job that is well beneath her training and experience?

Even if they can make the new numbers work, will Sarah find a peer group that will support her decision to stay home? Thirty years ago I wouldn't have thought to consider this question. But over the decades I have spoken to enough young mothers who have stayed home to hear that it can feel lonely at times without other women who share their perspective on the frustrations, fears, and successes of parenting.

If Sarah decides to quit her job and stay home, depending on her neighborhood, she will find herself in a small minority, maybe even alone. Will she find enough support to balance what she might perceive as a loss of status associated with stepping away from her career? I may be able to help by reminding her at each visit of the “firsts” she has witnessed by staying at home. And the control she has over things like Clay's sleep schedule and TV exposure.

So what did I tell Sarah today? First, I reminded her that past performance is no guarantee of success, but that whenever family members have shared with me their concerns about this kind of decision it has always worked out. It's not easy swimming against the societal norm, but I had a strong feeling that Sarah and Jason and Clay were going to make it work.

In the interest of gender equality, I must add that the arrangement can work well when the father is the parent who stays home.

[email protected]

How do you sleep when you're on call? To those of you who are hospital-based physicians or part of a very large and busy call group, this sounds like a silly question. Your answer will be that you are so busy that anything more than a 5-minute catnap while you are waiting for an x-ray is not an option. But, for those of us who may only get one or two calls after midnight – or some nights never have a call – getting sleep can present an awkward dilemma.

On one hand, we must be prepared to respond to a real, or usually just perceived, emergency. We must be able to speak intelligently (and intelligibly), think rationally, and perform fine motor tasks accurately after being aroused from any REM or non-REM state. On the other hand, we will be expected to show up at the office the next morning apparently well rested and prepared to make a few dozen clinical decisions in a thoughtful and compassionate manner. Can you do it? How do you do it?

I recently met with two physicians whom I hadn't seen in a while. Whenever aging physicians get together, the conversation eventually touches on the burden of taking call. One said he really could never sleep when he was on call, and the other said that he sleeps very poorly when it is his night in the barrel.

Strategies for a Good Night's Sleep

These revelations surprised me a bit coming from two physicians with a combined experience of nearly 60 years. I often hear from my partners who are 25 years younger that they can't sleep when they are on call. I try to reassure them that, as they did for me, things will get better, and they will learn or assimilate strategies that will allow them to get enough restorative sleep on the nights when they have drawn the short straw.

For example, I never let a patient leave the office until I am comfortable that I've have done everything I should (not could) in this clinical situation. If I think of something after we've all gone home, I'm not embarrassed to call to recheck the situation or tell them to go to the hospital lab for the lab work I've forgotten. Or tell them I will meet them in the ER so that I can have one more look before I go to bed. Shakespeare may have believed that sleep “knits up the raveled sleeves of care.” But if you go to bed with too many loose ends, you'll never get to sleep.

Experience should teach us to give better and better anticipatory guidance. The more questions and bumps in the road a physician can head off with a few preemptive and reassuring words when he/she is face to face with the parent, the more sleep everyone will get.

When I go to bed, I turn off my beeper and tell the answering service to have the parents call my home phone whose ringer has been muted with duct tape so it doesn't disturb Marilyn. This means no fumbling for a light or a pen. It eliminates those embarrassing misdialed numbers at 2 a.m. that begin, “This is Doctor Wilkoff.” It also makes parents consider one more time whether their question is worth waking me at home.

But, there is only so much we pediatricians can do to improve our chances of getting a good night's sleep. The most frustrating calls come from someone on the obstetrics floor who just wants to give me a “heads up” about some meconium-stained fluid or an expected preterm delivery. Unless the situation is so unusual I am going to need to hunt for some special equipment or consultant, I'm not sure how this information is going to help matters. Maybe it's just one of those “misery loves company” deals. But, I can guarantee one thing: It's certainly going to ruin my night's sleep.

[email protected]

How do you sleep when you're on call? To those of you who are hospital-based physicians or part of a very large and busy call group, this sounds like a silly question. Your answer will be that you are so busy that anything more than a 5-minute catnap while you are waiting for an x-ray is not an option. But, for those of us who may only get one or two calls after midnight – or some nights never have a call – getting sleep can present an awkward dilemma.

On one hand, we must be prepared to respond to a real, or usually just perceived, emergency. We must be able to speak intelligently (and intelligibly), think rationally, and perform fine motor tasks accurately after being aroused from any REM or non-REM state. On the other hand, we will be expected to show up at the office the next morning apparently well rested and prepared to make a few dozen clinical decisions in a thoughtful and compassionate manner. Can you do it? How do you do it?

I recently met with two physicians whom I hadn't seen in a while. Whenever aging physicians get together, the conversation eventually touches on the burden of taking call. One said he really could never sleep when he was on call, and the other said that he sleeps very poorly when it is his night in the barrel.

Strategies for a Good Night's Sleep

These revelations surprised me a bit coming from two physicians with a combined experience of nearly 60 years. I often hear from my partners who are 25 years younger that they can't sleep when they are on call. I try to reassure them that, as they did for me, things will get better, and they will learn or assimilate strategies that will allow them to get enough restorative sleep on the nights when they have drawn the short straw.

For example, I never let a patient leave the office until I am comfortable that I've have done everything I should (not could) in this clinical situation. If I think of something after we've all gone home, I'm not embarrassed to call to recheck the situation or tell them to go to the hospital lab for the lab work I've forgotten. Or tell them I will meet them in the ER so that I can have one more look before I go to bed. Shakespeare may have believed that sleep “knits up the raveled sleeves of care.” But if you go to bed with too many loose ends, you'll never get to sleep.

Experience should teach us to give better and better anticipatory guidance. The more questions and bumps in the road a physician can head off with a few preemptive and reassuring words when he/she is face to face with the parent, the more sleep everyone will get.

When I go to bed, I turn off my beeper and tell the answering service to have the parents call my home phone whose ringer has been muted with duct tape so it doesn't disturb Marilyn. This means no fumbling for a light or a pen. It eliminates those embarrassing misdialed numbers at 2 a.m. that begin, “This is Doctor Wilkoff.” It also makes parents consider one more time whether their question is worth waking me at home.

But, there is only so much we pediatricians can do to improve our chances of getting a good night's sleep. The most frustrating calls come from someone on the obstetrics floor who just wants to give me a “heads up” about some meconium-stained fluid or an expected preterm delivery. Unless the situation is so unusual I am going to need to hunt for some special equipment or consultant, I'm not sure how this information is going to help matters. Maybe it's just one of those “misery loves company” deals. But, I can guarantee one thing: It's certainly going to ruin my night's sleep.

[email protected]

How do you sleep when you're on call? To those of you who are hospital-based physicians or part of a very large and busy call group, this sounds like a silly question. Your answer will be that you are so busy that anything more than a 5-minute catnap while you are waiting for an x-ray is not an option. But, for those of us who may only get one or two calls after midnight – or some nights never have a call – getting sleep can present an awkward dilemma.

On one hand, we must be prepared to respond to a real, or usually just perceived, emergency. We must be able to speak intelligently (and intelligibly), think rationally, and perform fine motor tasks accurately after being aroused from any REM or non-REM state. On the other hand, we will be expected to show up at the office the next morning apparently well rested and prepared to make a few dozen clinical decisions in a thoughtful and compassionate manner. Can you do it? How do you do it?

I recently met with two physicians whom I hadn't seen in a while. Whenever aging physicians get together, the conversation eventually touches on the burden of taking call. One said he really could never sleep when he was on call, and the other said that he sleeps very poorly when it is his night in the barrel.

Strategies for a Good Night's Sleep

These revelations surprised me a bit coming from two physicians with a combined experience of nearly 60 years. I often hear from my partners who are 25 years younger that they can't sleep when they are on call. I try to reassure them that, as they did for me, things will get better, and they will learn or assimilate strategies that will allow them to get enough restorative sleep on the nights when they have drawn the short straw.

For example, I never let a patient leave the office until I am comfortable that I've have done everything I should (not could) in this clinical situation. If I think of something after we've all gone home, I'm not embarrassed to call to recheck the situation or tell them to go to the hospital lab for the lab work I've forgotten. Or tell them I will meet them in the ER so that I can have one more look before I go to bed. Shakespeare may have believed that sleep “knits up the raveled sleeves of care.” But if you go to bed with too many loose ends, you'll never get to sleep.

Experience should teach us to give better and better anticipatory guidance. The more questions and bumps in the road a physician can head off with a few preemptive and reassuring words when he/she is face to face with the parent, the more sleep everyone will get.

When I go to bed, I turn off my beeper and tell the answering service to have the parents call my home phone whose ringer has been muted with duct tape so it doesn't disturb Marilyn. This means no fumbling for a light or a pen. It eliminates those embarrassing misdialed numbers at 2 a.m. that begin, “This is Doctor Wilkoff.” It also makes parents consider one more time whether their question is worth waking me at home.

But, there is only so much we pediatricians can do to improve our chances of getting a good night's sleep. The most frustrating calls come from someone on the obstetrics floor who just wants to give me a “heads up” about some meconium-stained fluid or an expected preterm delivery. Unless the situation is so unusual I am going to need to hunt for some special equipment or consultant, I'm not sure how this information is going to help matters. Maybe it's just one of those “misery loves company” deals. But, I can guarantee one thing: It's certainly going to ruin my night's sleep.