Letters from Maine

I’m pretty sure my ancestors came from Europe. And, as far as I know, I have no relatives in Australia. But, I must have some cosmic relationship with the Land Down Under because as I review articles for these columns I have an uncanny attraction to those coming out of Australia. Most of them are about sleep, one of my obsessions, and in general they address simple questions that no one has thought to ask.

My most recent Australia-based nugget appeared in the August edition of Pediatrics.

The researchers in Sidney were seeking to define “growing pains” by embarking on an extensive review of the medical literature. Beginning with thousands of articles, they winnowed these down to 145 studies. They found “there was extremely poor consensus between studies.” The most consistent components were the lower limb, bilaterality, evening onset, a normal physical assessment, and an episodic or recurrent course. However, all of these factors were mentioned in 50% or less of the articles they reviewed. The investigators wisely concluded that clinicians “should be wary of relying on the diagnosis to direct treatment decisions.”

This may seem like one small step for pediatrics. You may have reassured parents that none of your patients ever died of “growing pains” and the condition would eventually resolve. Hopefully, you were correct and that your case rate fatality is zero. But I suspect it wouldn’t take too long to unearth a wealth of malpractices cases in which another pediatrician’s patient died with an illness whose eventual discovery was tragically delayed by a period of false reassurance and diagnosis that the child merely had growing pains.

I can’t remember which of my sage instructors told me to never use “growing pains” as a diagnosis. It may have just been something I stumbled upon as my clinical experience grew. While holding firm to my commitment to never use it as a diagnosis, it became abundantly clear that I was seeing a large group of children (toddlers to early adolescents) who were experiencing lower leg pains in the early evening, often bad enough to wake them.

It took a bit longer to discover that most often these painful episodes occurred in children who were acutely or chronically sleep deprived. Occasionally, the pain would come on days in which the child had been unusually physically active. However, in most cases there was little correlation with lower limb activity.

I will admit that my observations were colored by my growing obsession that sleep deprivation is the root of many evils, including the phenomenon known as attention-deficit/hyperactivity disorder. I was even bold enough to include it in my one of the books I have written (Is My Child Overtired? Simon & Schuster, 2001). Nonetheless, I am still convinced that every investigation of a child with evening leg pains should include a thorough history of the child’s sleep history.

The bottom line is that these Australian researchers have done us a great favor with their research. However, I think they should have made a bolder statement in their conclusion. It is clear to me that “growing pains” should be removed as a diagnosis and no longer be reimbursed by third-party payers.

The void created by that action should spur some research into a better-defined diagnosis of the condition. If you want to use my tack and label it “nocturnal leg pains of childhood” and suggest better sleep hygiene, I will be flattered. But more importantly, take the time to take a good history, do a thorough exam, and then follow up, follow up, follow up, until the problem resolves.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

I’m pretty sure my ancestors came from Europe. And, as far as I know, I have no relatives in Australia. But, I must have some cosmic relationship with the Land Down Under because as I review articles for these columns I have an uncanny attraction to those coming out of Australia. Most of them are about sleep, one of my obsessions, and in general they address simple questions that no one has thought to ask.

My most recent Australia-based nugget appeared in the August edition of Pediatrics.

The researchers in Sidney were seeking to define “growing pains” by embarking on an extensive review of the medical literature. Beginning with thousands of articles, they winnowed these down to 145 studies. They found “there was extremely poor consensus between studies.” The most consistent components were the lower limb, bilaterality, evening onset, a normal physical assessment, and an episodic or recurrent course. However, all of these factors were mentioned in 50% or less of the articles they reviewed. The investigators wisely concluded that clinicians “should be wary of relying on the diagnosis to direct treatment decisions.”

This may seem like one small step for pediatrics. You may have reassured parents that none of your patients ever died of “growing pains” and the condition would eventually resolve. Hopefully, you were correct and that your case rate fatality is zero. But I suspect it wouldn’t take too long to unearth a wealth of malpractices cases in which another pediatrician’s patient died with an illness whose eventual discovery was tragically delayed by a period of false reassurance and diagnosis that the child merely had growing pains.

I can’t remember which of my sage instructors told me to never use “growing pains” as a diagnosis. It may have just been something I stumbled upon as my clinical experience grew. While holding firm to my commitment to never use it as a diagnosis, it became abundantly clear that I was seeing a large group of children (toddlers to early adolescents) who were experiencing lower leg pains in the early evening, often bad enough to wake them.

It took a bit longer to discover that most often these painful episodes occurred in children who were acutely or chronically sleep deprived. Occasionally, the pain would come on days in which the child had been unusually physically active. However, in most cases there was little correlation with lower limb activity.

I will admit that my observations were colored by my growing obsession that sleep deprivation is the root of many evils, including the phenomenon known as attention-deficit/hyperactivity disorder. I was even bold enough to include it in my one of the books I have written (Is My Child Overtired? Simon & Schuster, 2001). Nonetheless, I am still convinced that every investigation of a child with evening leg pains should include a thorough history of the child’s sleep history.

The bottom line is that these Australian researchers have done us a great favor with their research. However, I think they should have made a bolder statement in their conclusion. It is clear to me that “growing pains” should be removed as a diagnosis and no longer be reimbursed by third-party payers.

The void created by that action should spur some research into a better-defined diagnosis of the condition. If you want to use my tack and label it “nocturnal leg pains of childhood” and suggest better sleep hygiene, I will be flattered. But more importantly, take the time to take a good history, do a thorough exam, and then follow up, follow up, follow up, until the problem resolves.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

I’m pretty sure my ancestors came from Europe. And, as far as I know, I have no relatives in Australia. But, I must have some cosmic relationship with the Land Down Under because as I review articles for these columns I have an uncanny attraction to those coming out of Australia. Most of them are about sleep, one of my obsessions, and in general they address simple questions that no one has thought to ask.

My most recent Australia-based nugget appeared in the August edition of Pediatrics.

The researchers in Sidney were seeking to define “growing pains” by embarking on an extensive review of the medical literature. Beginning with thousands of articles, they winnowed these down to 145 studies. They found “there was extremely poor consensus between studies.” The most consistent components were the lower limb, bilaterality, evening onset, a normal physical assessment, and an episodic or recurrent course. However, all of these factors were mentioned in 50% or less of the articles they reviewed. The investigators wisely concluded that clinicians “should be wary of relying on the diagnosis to direct treatment decisions.”

This may seem like one small step for pediatrics. You may have reassured parents that none of your patients ever died of “growing pains” and the condition would eventually resolve. Hopefully, you were correct and that your case rate fatality is zero. But I suspect it wouldn’t take too long to unearth a wealth of malpractices cases in which another pediatrician’s patient died with an illness whose eventual discovery was tragically delayed by a period of false reassurance and diagnosis that the child merely had growing pains.

I can’t remember which of my sage instructors told me to never use “growing pains” as a diagnosis. It may have just been something I stumbled upon as my clinical experience grew. While holding firm to my commitment to never use it as a diagnosis, it became abundantly clear that I was seeing a large group of children (toddlers to early adolescents) who were experiencing lower leg pains in the early evening, often bad enough to wake them.

It took a bit longer to discover that most often these painful episodes occurred in children who were acutely or chronically sleep deprived. Occasionally, the pain would come on days in which the child had been unusually physically active. However, in most cases there was little correlation with lower limb activity.

I will admit that my observations were colored by my growing obsession that sleep deprivation is the root of many evils, including the phenomenon known as attention-deficit/hyperactivity disorder. I was even bold enough to include it in my one of the books I have written (Is My Child Overtired? Simon & Schuster, 2001). Nonetheless, I am still convinced that every investigation of a child with evening leg pains should include a thorough history of the child’s sleep history.

The bottom line is that these Australian researchers have done us a great favor with their research. However, I think they should have made a bolder statement in their conclusion. It is clear to me that “growing pains” should be removed as a diagnosis and no longer be reimbursed by third-party payers.

The void created by that action should spur some research into a better-defined diagnosis of the condition. If you want to use my tack and label it “nocturnal leg pains of childhood” and suggest better sleep hygiene, I will be flattered. But more importantly, take the time to take a good history, do a thorough exam, and then follow up, follow up, follow up, until the problem resolves.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

“Children’s hospitals saw a more than 25% decline in injury-related emergency room visits during the first year of the pandemic.” There’s a headline that should soothe a nation starved for some good news. It was based on a study published in Pediatrics that reports on data collected in the Pediatric Health Information System between March 2020 and March 2021 using a 3-year period between 2017 and 2020 as a control. How could this not be good news? First, let’s not be too hasty in celebrating the good fortune of all those millions of children spared the pain and anxiety of an emergency department visit.

If you were an administrator of an emergency department attempting to match revenues with expenses, a 25% drop in visits may have hit your bottom line. Office-based pediatricians experienced a similar phenomenon when many parents quickly learned that they could ignore or self-manage minor illnesses and complaints.

A decrease in visits doesn’t necessarily mean that the conditions that drive the traffic flow in your facility have gone away. It may simply be that they are being managed somewhere else. However, it is equally likely that for some reason the pandemic created situations that made the usual illnesses and injuries that flood into emergency departments less likely to occur. And, here, other anecdotal evidence about weight gain and a decline in fitness point to the conclusion that when children are no longer in school, they settle into more sedentary and less injury-generating activities. Injuries from falling off the couch watching television or playing video games alone do occur but certainly with less frequency than the random collisions that are inevitable when scores of classmates are running around on the playground.

So while it may be tempting to view a decline in emergency department visits as a positive statistic, this pandemic should remind us to be careful about how we choose our metrics to measure the health of the community. A decline in injuries in the short term may be masking a more serious erosion in the health of the pediatric population over the long term. At times I worry that as a specialty we are so focused on injury prevention that we lose sight of the fact that being physically active comes with a risk. A risk that we may wish to minimize, but a risk we must accept if we want to encourage the physical activity that we know is so important in the bigger health picture. For example, emergency department visits caused by pedal cycles initially rose 60%, eventually settling into the 25%-30% range leading one to suspect there was a learning or relearning curve.

However, while visits for minor injuries declined 25%, those associated with firearms rose initially 22%, and then 42%, and finally over 35%. These numbers combined with significant increases in visits from suffocation, nonpedal transportation, and suicide intent make it clear that, for most children, being in school is significantly less dangerous than staying at home.

As the pandemic continues to tumble on and we are presented with future questions about whether to keep schools open or closed, I hope the results of this study and others will help school officials and their advisers step back and look beyond the simple metric of case numbers and appreciate that there are benefits to being in school that go far beyond what can be learned in class.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

“Children’s hospitals saw a more than 25% decline in injury-related emergency room visits during the first year of the pandemic.” There’s a headline that should soothe a nation starved for some good news. It was based on a study published in Pediatrics that reports on data collected in the Pediatric Health Information System between March 2020 and March 2021 using a 3-year period between 2017 and 2020 as a control. How could this not be good news? First, let’s not be too hasty in celebrating the good fortune of all those millions of children spared the pain and anxiety of an emergency department visit.

If you were an administrator of an emergency department attempting to match revenues with expenses, a 25% drop in visits may have hit your bottom line. Office-based pediatricians experienced a similar phenomenon when many parents quickly learned that they could ignore or self-manage minor illnesses and complaints.

A decrease in visits doesn’t necessarily mean that the conditions that drive the traffic flow in your facility have gone away. It may simply be that they are being managed somewhere else. However, it is equally likely that for some reason the pandemic created situations that made the usual illnesses and injuries that flood into emergency departments less likely to occur. And, here, other anecdotal evidence about weight gain and a decline in fitness point to the conclusion that when children are no longer in school, they settle into more sedentary and less injury-generating activities. Injuries from falling off the couch watching television or playing video games alone do occur but certainly with less frequency than the random collisions that are inevitable when scores of classmates are running around on the playground.

So while it may be tempting to view a decline in emergency department visits as a positive statistic, this pandemic should remind us to be careful about how we choose our metrics to measure the health of the community. A decline in injuries in the short term may be masking a more serious erosion in the health of the pediatric population over the long term. At times I worry that as a specialty we are so focused on injury prevention that we lose sight of the fact that being physically active comes with a risk. A risk that we may wish to minimize, but a risk we must accept if we want to encourage the physical activity that we know is so important in the bigger health picture. For example, emergency department visits caused by pedal cycles initially rose 60%, eventually settling into the 25%-30% range leading one to suspect there was a learning or relearning curve.

However, while visits for minor injuries declined 25%, those associated with firearms rose initially 22%, and then 42%, and finally over 35%. These numbers combined with significant increases in visits from suffocation, nonpedal transportation, and suicide intent make it clear that, for most children, being in school is significantly less dangerous than staying at home.

As the pandemic continues to tumble on and we are presented with future questions about whether to keep schools open or closed, I hope the results of this study and others will help school officials and their advisers step back and look beyond the simple metric of case numbers and appreciate that there are benefits to being in school that go far beyond what can be learned in class.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

“Children’s hospitals saw a more than 25% decline in injury-related emergency room visits during the first year of the pandemic.” There’s a headline that should soothe a nation starved for some good news. It was based on a study published in Pediatrics that reports on data collected in the Pediatric Health Information System between March 2020 and March 2021 using a 3-year period between 2017 and 2020 as a control. How could this not be good news? First, let’s not be too hasty in celebrating the good fortune of all those millions of children spared the pain and anxiety of an emergency department visit.

If you were an administrator of an emergency department attempting to match revenues with expenses, a 25% drop in visits may have hit your bottom line. Office-based pediatricians experienced a similar phenomenon when many parents quickly learned that they could ignore or self-manage minor illnesses and complaints.

A decrease in visits doesn’t necessarily mean that the conditions that drive the traffic flow in your facility have gone away. It may simply be that they are being managed somewhere else. However, it is equally likely that for some reason the pandemic created situations that made the usual illnesses and injuries that flood into emergency departments less likely to occur. And, here, other anecdotal evidence about weight gain and a decline in fitness point to the conclusion that when children are no longer in school, they settle into more sedentary and less injury-generating activities. Injuries from falling off the couch watching television or playing video games alone do occur but certainly with less frequency than the random collisions that are inevitable when scores of classmates are running around on the playground.

So while it may be tempting to view a decline in emergency department visits as a positive statistic, this pandemic should remind us to be careful about how we choose our metrics to measure the health of the community. A decline in injuries in the short term may be masking a more serious erosion in the health of the pediatric population over the long term. At times I worry that as a specialty we are so focused on injury prevention that we lose sight of the fact that being physically active comes with a risk. A risk that we may wish to minimize, but a risk we must accept if we want to encourage the physical activity that we know is so important in the bigger health picture. For example, emergency department visits caused by pedal cycles initially rose 60%, eventually settling into the 25%-30% range leading one to suspect there was a learning or relearning curve.

However, while visits for minor injuries declined 25%, those associated with firearms rose initially 22%, and then 42%, and finally over 35%. These numbers combined with significant increases in visits from suffocation, nonpedal transportation, and suicide intent make it clear that, for most children, being in school is significantly less dangerous than staying at home.

As the pandemic continues to tumble on and we are presented with future questions about whether to keep schools open or closed, I hope the results of this study and others will help school officials and their advisers step back and look beyond the simple metric of case numbers and appreciate that there are benefits to being in school that go far beyond what can be learned in class.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Tragic, embarrassing, criminal ... Choose your own adjective. The maternal mortality rate in this country is the worst of any developed nation in the world. And the numbers are getting worse with an increase of 14% over the previous year. One-third of these deaths occur weeks or months after the delivery.

In a recent issue of Harvard Public Health, researchers at the T.H. Chan School of Public Health discuss some of the possible remedies for what they describe as a crisis. While some of the solutions they list will require major restructuring of how we deliver health care to mothers, others could take advantage of our current systems by employing a slight shift in emphasis. And here is where those of us on the frontline of care delivery can make a difference.

The researchers point out that “More than 90% of maternal deaths could be prevented if women had access to quality care.” They also observe that most mothers have a single postpartum check with the ob.gyn. facility that delivered the baby and then are often left to navigate the health system because transfer to their primary care and/or mental health professional is haphazard or lacking in follow-up.

As I read through the article it struck me that as pediatricians we could and should be playing a larger role in this critical postpartum period when so many women seem to be falling through the cracks in our health care nonsystem. This is not a great “Ah-ha” moment for which I deserve any credit. In 2010 the American Academy of Pediatrics recommended that mothers be screened for depression at the 1-, 2-, and 4-month visits using either a validated 10-question screening instrument or a more direct 2-question tool (Pediatrics 2010;126[5]:1032-9). However, a periodic survey of AAP members 3 years later revealed that less than a third of the respondents were screening regularly for postpartum depression. In 2019 the academy reemphasized the important role that pediatric primary care givers can play in the detection and early management of the condition.

The reasons for the disappointing response include the list of usual suspects of inadequate training, workload demands, reimbursement, liability concerns, and the difficulty in finding and establishing effective referral networks. Unfortunately, these factors continue to exist, and many cases have multiplied in the wake of the pandemic.

In some states, educational outreach, funding, and changes in the reimbursement structure have resulted in improved outcomes. Not all of us are fortunate enough to live in a state that has made postpartum depression detection and management a priority. However, simply making it our own professional priority can save lives, ease suffering, and improve postpartum outcomes. Here I am talking about first caring and then inquiring about a mother’s mental health. Asking how much sleep she is getting. And then spending the time to give personalized advice on feeding and sleep schedules. Even, if this means ignoring half of the topics on the recommended health maintenance. It doesn’t take but a few minutes to convince yourself that the baby is healthy, and you know that 90% of them are.

However, a new mother who is sleep deprived and already has one foot on the spiral staircase down into postpartum depression represents an emergency. And, you should have the skills to turn it around. But, you have to care about the problem and make it your own priority – high enough on the list to make a follow-up appointment or call in a week instead of waiting a month or 2 until the next visit.

Unfortunately, even with your best efforts there are some families who need services beyond the scope of your practice. Making the necessary referrals can be frustrating and time consuming but not dropping ball until it lands in the appropriate place may save a life.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Tragic, embarrassing, criminal ... Choose your own adjective. The maternal mortality rate in this country is the worst of any developed nation in the world. And the numbers are getting worse with an increase of 14% over the previous year. One-third of these deaths occur weeks or months after the delivery.

In a recent issue of Harvard Public Health, researchers at the T.H. Chan School of Public Health discuss some of the possible remedies for what they describe as a crisis. While some of the solutions they list will require major restructuring of how we deliver health care to mothers, others could take advantage of our current systems by employing a slight shift in emphasis. And here is where those of us on the frontline of care delivery can make a difference.

The researchers point out that “More than 90% of maternal deaths could be prevented if women had access to quality care.” They also observe that most mothers have a single postpartum check with the ob.gyn. facility that delivered the baby and then are often left to navigate the health system because transfer to their primary care and/or mental health professional is haphazard or lacking in follow-up.

As I read through the article it struck me that as pediatricians we could and should be playing a larger role in this critical postpartum period when so many women seem to be falling through the cracks in our health care nonsystem. This is not a great “Ah-ha” moment for which I deserve any credit. In 2010 the American Academy of Pediatrics recommended that mothers be screened for depression at the 1-, 2-, and 4-month visits using either a validated 10-question screening instrument or a more direct 2-question tool (Pediatrics 2010;126[5]:1032-9). However, a periodic survey of AAP members 3 years later revealed that less than a third of the respondents were screening regularly for postpartum depression. In 2019 the academy reemphasized the important role that pediatric primary care givers can play in the detection and early management of the condition.

The reasons for the disappointing response include the list of usual suspects of inadequate training, workload demands, reimbursement, liability concerns, and the difficulty in finding and establishing effective referral networks. Unfortunately, these factors continue to exist, and many cases have multiplied in the wake of the pandemic.

In some states, educational outreach, funding, and changes in the reimbursement structure have resulted in improved outcomes. Not all of us are fortunate enough to live in a state that has made postpartum depression detection and management a priority. However, simply making it our own professional priority can save lives, ease suffering, and improve postpartum outcomes. Here I am talking about first caring and then inquiring about a mother’s mental health. Asking how much sleep she is getting. And then spending the time to give personalized advice on feeding and sleep schedules. Even, if this means ignoring half of the topics on the recommended health maintenance. It doesn’t take but a few minutes to convince yourself that the baby is healthy, and you know that 90% of them are.

However, a new mother who is sleep deprived and already has one foot on the spiral staircase down into postpartum depression represents an emergency. And, you should have the skills to turn it around. But, you have to care about the problem and make it your own priority – high enough on the list to make a follow-up appointment or call in a week instead of waiting a month or 2 until the next visit.

Unfortunately, even with your best efforts there are some families who need services beyond the scope of your practice. Making the necessary referrals can be frustrating and time consuming but not dropping ball until it lands in the appropriate place may save a life.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Tragic, embarrassing, criminal ... Choose your own adjective. The maternal mortality rate in this country is the worst of any developed nation in the world. And the numbers are getting worse with an increase of 14% over the previous year. One-third of these deaths occur weeks or months after the delivery.

In a recent issue of Harvard Public Health, researchers at the T.H. Chan School of Public Health discuss some of the possible remedies for what they describe as a crisis. While some of the solutions they list will require major restructuring of how we deliver health care to mothers, others could take advantage of our current systems by employing a slight shift in emphasis. And here is where those of us on the frontline of care delivery can make a difference.

The researchers point out that “More than 90% of maternal deaths could be prevented if women had access to quality care.” They also observe that most mothers have a single postpartum check with the ob.gyn. facility that delivered the baby and then are often left to navigate the health system because transfer to their primary care and/or mental health professional is haphazard or lacking in follow-up.

As I read through the article it struck me that as pediatricians we could and should be playing a larger role in this critical postpartum period when so many women seem to be falling through the cracks in our health care nonsystem. This is not a great “Ah-ha” moment for which I deserve any credit. In 2010 the American Academy of Pediatrics recommended that mothers be screened for depression at the 1-, 2-, and 4-month visits using either a validated 10-question screening instrument or a more direct 2-question tool (Pediatrics 2010;126[5]:1032-9). However, a periodic survey of AAP members 3 years later revealed that less than a third of the respondents were screening regularly for postpartum depression. In 2019 the academy reemphasized the important role that pediatric primary care givers can play in the detection and early management of the condition.

The reasons for the disappointing response include the list of usual suspects of inadequate training, workload demands, reimbursement, liability concerns, and the difficulty in finding and establishing effective referral networks. Unfortunately, these factors continue to exist, and many cases have multiplied in the wake of the pandemic.

In some states, educational outreach, funding, and changes in the reimbursement structure have resulted in improved outcomes. Not all of us are fortunate enough to live in a state that has made postpartum depression detection and management a priority. However, simply making it our own professional priority can save lives, ease suffering, and improve postpartum outcomes. Here I am talking about first caring and then inquiring about a mother’s mental health. Asking how much sleep she is getting. And then spending the time to give personalized advice on feeding and sleep schedules. Even, if this means ignoring half of the topics on the recommended health maintenance. It doesn’t take but a few minutes to convince yourself that the baby is healthy, and you know that 90% of them are.

However, a new mother who is sleep deprived and already has one foot on the spiral staircase down into postpartum depression represents an emergency. And, you should have the skills to turn it around. But, you have to care about the problem and make it your own priority – high enough on the list to make a follow-up appointment or call in a week instead of waiting a month or 2 until the next visit.

Unfortunately, even with your best efforts there are some families who need services beyond the scope of your practice. Making the necessary referrals can be frustrating and time consuming but not dropping ball until it lands in the appropriate place may save a life.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

The American Academy of Pediatrics is built on good intentions. It wants the best for children in the world, and it hopes to support its members in their efforts to achieve this goal. But from time to time, the academy loses sight of reality and makes recommendations that are counterproductive to its stated goals.

The recent release of its new policy “Breastfeeding and the Use of Human Milk” is another unfortunate example of poorly aimed recommendations. A careful reading of the document reveals it to be a well-researched treatise on breastfeeding and the value of human milk, including a discussion of the numerous impediments to the universal adoption of breastfeeding in our society. However, when a document of this breadth and complexity is released to the public it is never surprising that the messages deserving the most attention are lost in the press coverage. Most of the headlines I saw mentioned pediatricians supporting breastfeeding for a year or 2.

Who was the target audience? If it was pediatricians, most of us don’t need a longer list of the health benefits of breastfeeding. We already believe it is the best nutritional source for human babies and realize that the institutional framework in this country continues to be unfriendly to women who intend to breastfeed.

If the audience is politicians and public health decision-makers, the new policy contains a wealth of supportive evidence. However, most pediatricians I know are too busy or lack the skills and enthusiasm to become political activists. For the rest of population, including parents, the recommendations represent a collection of TMI (too much information).

If the audience is women who are considering breastfeeding I suspect nearly 100% already know pediatricians think it is the preferred way to feed their babies. And, likewise, a longer list won’t convince them to try nursing. Additional evidence may simply make them feel more guilty when they aren’t successful.

Many pregnant women have already been told that breastfeeding can be a challenge and given their situation breast milk alone for the first 6 months may sound like an unreasonable goal. The new recommendation that breastfeeding for a year or 2 is good is not a message they want to hear.

On the other hand, if the target audience is women who will be comforted to hear an official statement that normalizes breastfeeding longer than a year, the new policy statement has hit the nail on the head.

Of course the new policy document is sprinkled with caveats that vaguely hint at the possibility that pediatricians are sensitive human beings who under certain circumstances may be able to compromise when it comes to the duration of breastfeeding and the introduction of formula. But this whiff of reality is certainly not the dominant odor in these new recommendations.

Don’t get me wrong: I think the academy was overdue for a policy revision on breastfeeding. However, it should have been one that was reality based. It should acknowledge that there are institutional and societal biases against breastfeeding, and it should remind pediatricians that they can effect change by discussing these realities honestly with parents, while making it clear that we are there for them and their children regardless of how they feed their baby. Pediatricians believe that breastfeeding is the best but not the only way to feed a baby. We have (or will provide) the skills to assist parents succeed in whatever method they choose and strive to minimize the impediments that are within our power to change.

If the academy had chosen to release a separate statement simply supporting mothers who chose to nurse longer than a year, then that would have been a good idea. However, when presented as part of the larger document, that message dominated in the media and only served to fuel the guilt that many new mothers must endure.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

The American Academy of Pediatrics is built on good intentions. It wants the best for children in the world, and it hopes to support its members in their efforts to achieve this goal. But from time to time, the academy loses sight of reality and makes recommendations that are counterproductive to its stated goals.

The recent release of its new policy “Breastfeeding and the Use of Human Milk” is another unfortunate example of poorly aimed recommendations. A careful reading of the document reveals it to be a well-researched treatise on breastfeeding and the value of human milk, including a discussion of the numerous impediments to the universal adoption of breastfeeding in our society. However, when a document of this breadth and complexity is released to the public it is never surprising that the messages deserving the most attention are lost in the press coverage. Most of the headlines I saw mentioned pediatricians supporting breastfeeding for a year or 2.

Who was the target audience? If it was pediatricians, most of us don’t need a longer list of the health benefits of breastfeeding. We already believe it is the best nutritional source for human babies and realize that the institutional framework in this country continues to be unfriendly to women who intend to breastfeed.

If the audience is politicians and public health decision-makers, the new policy contains a wealth of supportive evidence. However, most pediatricians I know are too busy or lack the skills and enthusiasm to become political activists. For the rest of population, including parents, the recommendations represent a collection of TMI (too much information).

If the audience is women who are considering breastfeeding I suspect nearly 100% already know pediatricians think it is the preferred way to feed their babies. And, likewise, a longer list won’t convince them to try nursing. Additional evidence may simply make them feel more guilty when they aren’t successful.

Many pregnant women have already been told that breastfeeding can be a challenge and given their situation breast milk alone for the first 6 months may sound like an unreasonable goal. The new recommendation that breastfeeding for a year or 2 is good is not a message they want to hear.

On the other hand, if the target audience is women who will be comforted to hear an official statement that normalizes breastfeeding longer than a year, the new policy statement has hit the nail on the head.

Of course the new policy document is sprinkled with caveats that vaguely hint at the possibility that pediatricians are sensitive human beings who under certain circumstances may be able to compromise when it comes to the duration of breastfeeding and the introduction of formula. But this whiff of reality is certainly not the dominant odor in these new recommendations.

Don’t get me wrong: I think the academy was overdue for a policy revision on breastfeeding. However, it should have been one that was reality based. It should acknowledge that there are institutional and societal biases against breastfeeding, and it should remind pediatricians that they can effect change by discussing these realities honestly with parents, while making it clear that we are there for them and their children regardless of how they feed their baby. Pediatricians believe that breastfeeding is the best but not the only way to feed a baby. We have (or will provide) the skills to assist parents succeed in whatever method they choose and strive to minimize the impediments that are within our power to change.

If the academy had chosen to release a separate statement simply supporting mothers who chose to nurse longer than a year, then that would have been a good idea. However, when presented as part of the larger document, that message dominated in the media and only served to fuel the guilt that many new mothers must endure.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

The American Academy of Pediatrics is built on good intentions. It wants the best for children in the world, and it hopes to support its members in their efforts to achieve this goal. But from time to time, the academy loses sight of reality and makes recommendations that are counterproductive to its stated goals.

The recent release of its new policy “Breastfeeding and the Use of Human Milk” is another unfortunate example of poorly aimed recommendations. A careful reading of the document reveals it to be a well-researched treatise on breastfeeding and the value of human milk, including a discussion of the numerous impediments to the universal adoption of breastfeeding in our society. However, when a document of this breadth and complexity is released to the public it is never surprising that the messages deserving the most attention are lost in the press coverage. Most of the headlines I saw mentioned pediatricians supporting breastfeeding for a year or 2.

Who was the target audience? If it was pediatricians, most of us don’t need a longer list of the health benefits of breastfeeding. We already believe it is the best nutritional source for human babies and realize that the institutional framework in this country continues to be unfriendly to women who intend to breastfeed.

If the audience is politicians and public health decision-makers, the new policy contains a wealth of supportive evidence. However, most pediatricians I know are too busy or lack the skills and enthusiasm to become political activists. For the rest of population, including parents, the recommendations represent a collection of TMI (too much information).

If the audience is women who are considering breastfeeding I suspect nearly 100% already know pediatricians think it is the preferred way to feed their babies. And, likewise, a longer list won’t convince them to try nursing. Additional evidence may simply make them feel more guilty when they aren’t successful.

Many pregnant women have already been told that breastfeeding can be a challenge and given their situation breast milk alone for the first 6 months may sound like an unreasonable goal. The new recommendation that breastfeeding for a year or 2 is good is not a message they want to hear.

On the other hand, if the target audience is women who will be comforted to hear an official statement that normalizes breastfeeding longer than a year, the new policy statement has hit the nail on the head.

Of course the new policy document is sprinkled with caveats that vaguely hint at the possibility that pediatricians are sensitive human beings who under certain circumstances may be able to compromise when it comes to the duration of breastfeeding and the introduction of formula. But this whiff of reality is certainly not the dominant odor in these new recommendations.

Don’t get me wrong: I think the academy was overdue for a policy revision on breastfeeding. However, it should have been one that was reality based. It should acknowledge that there are institutional and societal biases against breastfeeding, and it should remind pediatricians that they can effect change by discussing these realities honestly with parents, while making it clear that we are there for them and their children regardless of how they feed their baby. Pediatricians believe that breastfeeding is the best but not the only way to feed a baby. We have (or will provide) the skills to assist parents succeed in whatever method they choose and strive to minimize the impediments that are within our power to change.

If the academy had chosen to release a separate statement simply supporting mothers who chose to nurse longer than a year, then that would have been a good idea. However, when presented as part of the larger document, that message dominated in the media and only served to fuel the guilt that many new mothers must endure.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Concerns about the potential harm resulting from overzealous training regimens and performance schedules for young elite athletes seems to come in cycles much like the Olympics. But, more recently, the media attention has become more intense fueled by the very visible psychological vulnerabilities of some young gymnasts, tennis players, and figure skaters. Accusations of physical and psychological abuse by team physicians and coaches continue to surface with troubling regularity.

A recent article in the Wall St. Journal explores a variety of initiatives aimed at redefining the relationship between youth sports and the physical and mental health of its elite athletes. (Louise Radnofsky, The Wall Street Journal, June 9, 2022).

An example of the new awareness is the recent invitation of Peter Donnelly, PhD, an emeritus professor at the University of Toronto and long-time advocate for regulatory protections for youth athletes, to deliver a paper at a global conference in South Africa devoted to the elimination of child labor. Referring to youth sports, Dr. Donnelly observes “What if McDonalds had the same accident rate? ... There would be huge commissions of inquiry, regulations, and policies.” He suggests that the United Nations Convention on the Rights of the Child might be a mechanism to address the problem.

Writing in the Marquette University Sports Law Review in 2015, Kristin Hoffman, a law student at the time, suggested that the federal Fair Labor Standards Act or state child labor laws could be used to restructure sports like gymnastics or figure skating with tarnished histories. California law prohibits child actors from working more than 5 hours a day on school days and 7 hours on nonschool days but says little about child athletes. On paper, the National Collegiate Athletic Association limits college athletes to 20 hours participation per week but teenagers on club teams are not limited and may sometimes practice 30 hours or more.

Regulation in any form is a tough sell in this country. Coaches, parents, and athletes caught up in the myth that more repetitions and more touches on the ball are always the ticket to success will argue that most elite athletes are self-motivated and don’t view the long hours as a hardship.

Exactly how many are self-driven and how many are being pushed by parents and coaches is unknown. Across the street from us lived a young girl who, despite not having the obvious physical gifts, was clearly committed to excel in sports. She begged her parents to set up lights to allow her to practice well into the evening. She went on to have a good college career as a player and a very successful career as a Division I coach. Now in retirement, she is very open about her mental health history that in large part explains her inner drive and her subsequent troubles.

We need to be realistic in our hope for regulating the current state of youth sports out of its current situation. State laws that put reasonable limits on the hourly commitment to sports much like the California child actor laws feel like a reasonable goal. However, as physicians for these young athletes we must take each child – and we must remind ourselves that they are still children – as an individual.

When faced with patients who are clearly on the elite sport pathway, our goal is to protect their health – both physical and mental. If they are having symptoms of overuse we need to help them find alternative activities that will rest their injuries but still allow them to satisfy their competitive zeal. However, we must be ever alert to the risk that what appears to be unusual self-motivation may be instead a warning that pathologic obsession and compulsion lurk below the surface.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Concerns about the potential harm resulting from overzealous training regimens and performance schedules for young elite athletes seems to come in cycles much like the Olympics. But, more recently, the media attention has become more intense fueled by the very visible psychological vulnerabilities of some young gymnasts, tennis players, and figure skaters. Accusations of physical and psychological abuse by team physicians and coaches continue to surface with troubling regularity.

A recent article in the Wall St. Journal explores a variety of initiatives aimed at redefining the relationship between youth sports and the physical and mental health of its elite athletes. (Louise Radnofsky, The Wall Street Journal, June 9, 2022).

An example of the new awareness is the recent invitation of Peter Donnelly, PhD, an emeritus professor at the University of Toronto and long-time advocate for regulatory protections for youth athletes, to deliver a paper at a global conference in South Africa devoted to the elimination of child labor. Referring to youth sports, Dr. Donnelly observes “What if McDonalds had the same accident rate? ... There would be huge commissions of inquiry, regulations, and policies.” He suggests that the United Nations Convention on the Rights of the Child might be a mechanism to address the problem.

Writing in the Marquette University Sports Law Review in 2015, Kristin Hoffman, a law student at the time, suggested that the federal Fair Labor Standards Act or state child labor laws could be used to restructure sports like gymnastics or figure skating with tarnished histories. California law prohibits child actors from working more than 5 hours a day on school days and 7 hours on nonschool days but says little about child athletes. On paper, the National Collegiate Athletic Association limits college athletes to 20 hours participation per week but teenagers on club teams are not limited and may sometimes practice 30 hours or more.

Regulation in any form is a tough sell in this country. Coaches, parents, and athletes caught up in the myth that more repetitions and more touches on the ball are always the ticket to success will argue that most elite athletes are self-motivated and don’t view the long hours as a hardship.

Exactly how many are self-driven and how many are being pushed by parents and coaches is unknown. Across the street from us lived a young girl who, despite not having the obvious physical gifts, was clearly committed to excel in sports. She begged her parents to set up lights to allow her to practice well into the evening. She went on to have a good college career as a player and a very successful career as a Division I coach. Now in retirement, she is very open about her mental health history that in large part explains her inner drive and her subsequent troubles.

We need to be realistic in our hope for regulating the current state of youth sports out of its current situation. State laws that put reasonable limits on the hourly commitment to sports much like the California child actor laws feel like a reasonable goal. However, as physicians for these young athletes we must take each child – and we must remind ourselves that they are still children – as an individual.

When faced with patients who are clearly on the elite sport pathway, our goal is to protect their health – both physical and mental. If they are having symptoms of overuse we need to help them find alternative activities that will rest their injuries but still allow them to satisfy their competitive zeal. However, we must be ever alert to the risk that what appears to be unusual self-motivation may be instead a warning that pathologic obsession and compulsion lurk below the surface.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Concerns about the potential harm resulting from overzealous training regimens and performance schedules for young elite athletes seems to come in cycles much like the Olympics. But, more recently, the media attention has become more intense fueled by the very visible psychological vulnerabilities of some young gymnasts, tennis players, and figure skaters. Accusations of physical and psychological abuse by team physicians and coaches continue to surface with troubling regularity.

A recent article in the Wall St. Journal explores a variety of initiatives aimed at redefining the relationship between youth sports and the physical and mental health of its elite athletes. (Louise Radnofsky, The Wall Street Journal, June 9, 2022).

An example of the new awareness is the recent invitation of Peter Donnelly, PhD, an emeritus professor at the University of Toronto and long-time advocate for regulatory protections for youth athletes, to deliver a paper at a global conference in South Africa devoted to the elimination of child labor. Referring to youth sports, Dr. Donnelly observes “What if McDonalds had the same accident rate? ... There would be huge commissions of inquiry, regulations, and policies.” He suggests that the United Nations Convention on the Rights of the Child might be a mechanism to address the problem.

Writing in the Marquette University Sports Law Review in 2015, Kristin Hoffman, a law student at the time, suggested that the federal Fair Labor Standards Act or state child labor laws could be used to restructure sports like gymnastics or figure skating with tarnished histories. California law prohibits child actors from working more than 5 hours a day on school days and 7 hours on nonschool days but says little about child athletes. On paper, the National Collegiate Athletic Association limits college athletes to 20 hours participation per week but teenagers on club teams are not limited and may sometimes practice 30 hours or more.

Regulation in any form is a tough sell in this country. Coaches, parents, and athletes caught up in the myth that more repetitions and more touches on the ball are always the ticket to success will argue that most elite athletes are self-motivated and don’t view the long hours as a hardship.

Exactly how many are self-driven and how many are being pushed by parents and coaches is unknown. Across the street from us lived a young girl who, despite not having the obvious physical gifts, was clearly committed to excel in sports. She begged her parents to set up lights to allow her to practice well into the evening. She went on to have a good college career as a player and a very successful career as a Division I coach. Now in retirement, she is very open about her mental health history that in large part explains her inner drive and her subsequent troubles.

We need to be realistic in our hope for regulating the current state of youth sports out of its current situation. State laws that put reasonable limits on the hourly commitment to sports much like the California child actor laws feel like a reasonable goal. However, as physicians for these young athletes we must take each child – and we must remind ourselves that they are still children – as an individual.

When faced with patients who are clearly on the elite sport pathway, our goal is to protect their health – both physical and mental. If they are having symptoms of overuse we need to help them find alternative activities that will rest their injuries but still allow them to satisfy their competitive zeal. However, we must be ever alert to the risk that what appears to be unusual self-motivation may be instead a warning that pathologic obsession and compulsion lurk below the surface.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

I can dimly recall watching Queen Elizabeth’s coronation on a very small black and white television screen. Even in monochrome it was a riveting event. Recently, the Queen celebrated her Platinum Jubilee, marking her 70-year reign. Apparently it was a multiday event with all the trappings, floating above an undercurrent of scandal and intrigue. I had better things to do than I did as a 7-year-old entranced by the novelty of a neighbor’s television set.

But, it turns out that I had missed the opportunity to see live and in color a royal meltdown starring the Queen’s great-grandson, 4-year-old Prince Louis. Not to worry. It remains on video archives for our education and pleasure ad infinitum. His performance was no more dramatic than what you have seen numerous times in the checkout line of the grocery store. However, this meltdown was on the world stage in the front row of the royal box and performed in various venues on each day of a 4-day event.

As long as you weren’t his parents, Kate Middleton and Prince William, the meltdown had its moments of hilarity. Louis made full use of his youthful and plastic face, creating a wide variety of taunts and responses to his mother’s praiseworthy and understated attempts at regaining control. Of course, the British press and every armchair parent with a Twitter account had a field day contributing their explanations and advice.

For example, here’s the headline on an international news website that caught my eye: “Royal reveals why Prince Louis was so ‘mischievous’ during the Jubilee”. In the article, a fellow royal and former rugby star who was sitting directly behind the little Prince during one of his performances chalked up the 4-year-old’s behavior to a “sugar high” resulting from the ample supply of sweets available behind the royal box.

Nowhere in the article is there a question of whether the “sugar high” is a science-based phenomenon. In fact, the reporter assumes we all know it exists and writes that “parents across the globe can probably [read: definitely] relate.”

I’m curious: How do you respond when a parent in the office explains the child’s behavior as the result of a “sugar high”? Or when you’re at a cookout and someone makes a comment that makes it obvious that they believe that “sugar highs” are real? Do you immediately pause the conversation and launch into a short but tasteful observation that you know of no scientific studies that sugar can cause a high? Or, figuring that in the face of an overwhelming burden of old wives’ tales it’s not worth mounting a rebuttal, do you pretend you didn’t hear the comment?

Or am I completely off base because your experience has left you convinced that despite the lack of supporting studies the “sugar high” phenomenon exists? Maybe you even include it on your list of explanations and remedies for pediatric misbehaviors. I am ready to listen, but it will take some heavy lifting to convince me.

I suspect your response to offhand comments about “sugar highs” is similar to mine. It depends on the situation. If I think there are obvious and correctable causes for the child’s misbehavior such as sleep deprivation or a mismatch between parental expectation and the child’s tolerance for a stimulating environment I will include in my parenting advice the comment, “Sugar highs probably don’t exist.”

On the other hand, if I’m tired and think my observation will fall on deaf ears I let the conversation drift. I worry that my silence will be interpreted as a confirmation of an old wives’ tale. What I really don’t want to do is perpetuate a myth that may prevent some children from getting the care they need.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

I can dimly recall watching Queen Elizabeth’s coronation on a very small black and white television screen. Even in monochrome it was a riveting event. Recently, the Queen celebrated her Platinum Jubilee, marking her 70-year reign. Apparently it was a multiday event with all the trappings, floating above an undercurrent of scandal and intrigue. I had better things to do than I did as a 7-year-old entranced by the novelty of a neighbor’s television set.

But, it turns out that I had missed the opportunity to see live and in color a royal meltdown starring the Queen’s great-grandson, 4-year-old Prince Louis. Not to worry. It remains on video archives for our education and pleasure ad infinitum. His performance was no more dramatic than what you have seen numerous times in the checkout line of the grocery store. However, this meltdown was on the world stage in the front row of the royal box and performed in various venues on each day of a 4-day event.

As long as you weren’t his parents, Kate Middleton and Prince William, the meltdown had its moments of hilarity. Louis made full use of his youthful and plastic face, creating a wide variety of taunts and responses to his mother’s praiseworthy and understated attempts at regaining control. Of course, the British press and every armchair parent with a Twitter account had a field day contributing their explanations and advice.

For example, here’s the headline on an international news website that caught my eye: “Royal reveals why Prince Louis was so ‘mischievous’ during the Jubilee”. In the article, a fellow royal and former rugby star who was sitting directly behind the little Prince during one of his performances chalked up the 4-year-old’s behavior to a “sugar high” resulting from the ample supply of sweets available behind the royal box.

Nowhere in the article is there a question of whether the “sugar high” is a science-based phenomenon. In fact, the reporter assumes we all know it exists and writes that “parents across the globe can probably [read: definitely] relate.”

I’m curious: How do you respond when a parent in the office explains the child’s behavior as the result of a “sugar high”? Or when you’re at a cookout and someone makes a comment that makes it obvious that they believe that “sugar highs” are real? Do you immediately pause the conversation and launch into a short but tasteful observation that you know of no scientific studies that sugar can cause a high? Or, figuring that in the face of an overwhelming burden of old wives’ tales it’s not worth mounting a rebuttal, do you pretend you didn’t hear the comment?

Or am I completely off base because your experience has left you convinced that despite the lack of supporting studies the “sugar high” phenomenon exists? Maybe you even include it on your list of explanations and remedies for pediatric misbehaviors. I am ready to listen, but it will take some heavy lifting to convince me.

I suspect your response to offhand comments about “sugar highs” is similar to mine. It depends on the situation. If I think there are obvious and correctable causes for the child’s misbehavior such as sleep deprivation or a mismatch between parental expectation and the child’s tolerance for a stimulating environment I will include in my parenting advice the comment, “Sugar highs probably don’t exist.”

On the other hand, if I’m tired and think my observation will fall on deaf ears I let the conversation drift. I worry that my silence will be interpreted as a confirmation of an old wives’ tale. What I really don’t want to do is perpetuate a myth that may prevent some children from getting the care they need.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

I can dimly recall watching Queen Elizabeth’s coronation on a very small black and white television screen. Even in monochrome it was a riveting event. Recently, the Queen celebrated her Platinum Jubilee, marking her 70-year reign. Apparently it was a multiday event with all the trappings, floating above an undercurrent of scandal and intrigue. I had better things to do than I did as a 7-year-old entranced by the novelty of a neighbor’s television set.

But, it turns out that I had missed the opportunity to see live and in color a royal meltdown starring the Queen’s great-grandson, 4-year-old Prince Louis. Not to worry. It remains on video archives for our education and pleasure ad infinitum. His performance was no more dramatic than what you have seen numerous times in the checkout line of the grocery store. However, this meltdown was on the world stage in the front row of the royal box and performed in various venues on each day of a 4-day event.

As long as you weren’t his parents, Kate Middleton and Prince William, the meltdown had its moments of hilarity. Louis made full use of his youthful and plastic face, creating a wide variety of taunts and responses to his mother’s praiseworthy and understated attempts at regaining control. Of course, the British press and every armchair parent with a Twitter account had a field day contributing their explanations and advice.

For example, here’s the headline on an international news website that caught my eye: “Royal reveals why Prince Louis was so ‘mischievous’ during the Jubilee”. In the article, a fellow royal and former rugby star who was sitting directly behind the little Prince during one of his performances chalked up the 4-year-old’s behavior to a “sugar high” resulting from the ample supply of sweets available behind the royal box.

Nowhere in the article is there a question of whether the “sugar high” is a science-based phenomenon. In fact, the reporter assumes we all know it exists and writes that “parents across the globe can probably [read: definitely] relate.”

I’m curious: How do you respond when a parent in the office explains the child’s behavior as the result of a “sugar high”? Or when you’re at a cookout and someone makes a comment that makes it obvious that they believe that “sugar highs” are real? Do you immediately pause the conversation and launch into a short but tasteful observation that you know of no scientific studies that sugar can cause a high? Or, figuring that in the face of an overwhelming burden of old wives’ tales it’s not worth mounting a rebuttal, do you pretend you didn’t hear the comment?

Or am I completely off base because your experience has left you convinced that despite the lack of supporting studies the “sugar high” phenomenon exists? Maybe you even include it on your list of explanations and remedies for pediatric misbehaviors. I am ready to listen, but it will take some heavy lifting to convince me.

I suspect your response to offhand comments about “sugar highs” is similar to mine. It depends on the situation. If I think there are obvious and correctable causes for the child’s misbehavior such as sleep deprivation or a mismatch between parental expectation and the child’s tolerance for a stimulating environment I will include in my parenting advice the comment, “Sugar highs probably don’t exist.”

On the other hand, if I’m tired and think my observation will fall on deaf ears I let the conversation drift. I worry that my silence will be interpreted as a confirmation of an old wives’ tale. What I really don’t want to do is perpetuate a myth that may prevent some children from getting the care they need.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

It’s no secret that the fitness level of all age groups in our country is poor. A recent study in Pediatrics sharpens the focus on the question of how we might address the problem in the teenage population. Based in England, the investigators placed wrist accelerometers on their 13- and 14-year-old subjects who were then assessed using shuttle runs at progressively faster speeds.

The researchers found that the participants’ cardiorespiratory fitness improved as the subjects’ time doing vigorous activity increased up to 20 minutes and then plateaued. The study authors could not prove that the vigorous activity caused the increased in fitness. However, they were impressed by the plateau phenomenon and suggest that this might suggest a change in the recommendations by the World Health Organization and U.S. Department of Health & Human Services which currently call for 60 minutes of moderate to vigorous physical activity per day for adolescents

At first blush a shift down to 20 minutes of vigorous activity would appear to be workable and achievable. This would be particularly true for public school systems that are already struggling to get any kind of activity shoehorned into their schedules that are already crammed in an attempt to address mandated academic achievement goals. Freeing up an additional 40 minutes of the school day and yielding improved cardiorespiratory fitness sounds like a win-win.

But, let’s take a deep breath and for a few moments return to the world of reality. First, how many school systems are providing that 60 minutes of moderate activity (let’s forget the vigorous piece for the moment) included in the current WHO/HHS recommendations? Next, let’s take a look at what “vigorous” activity means. There are variety of definitions but in general they include sweating, flushing, and dyspnea to the point of having difficulty speaking.

Let’s just focus on the “sweating” part. To me that sounds like an activity that would require some wardrobe alteration at a minimum and very likely a locker room and a shower. Those can be fightin’ words for many teenagers. Even if a school can provide adequate locker room and shower infrastructure change-ups and showers are time-gobbling activities. And, more realistically, what are the chances of getting body image–challenged adolescents to willingly take advantage of them? You don’t have to talk to very many adults before you will hear stories of discomfort and embarrassment resulting from forced locker room and shower experiences. When I was a teenager the only way you could flunk physical education was to refuse to go in the locker room and “change up.” I think or at least hope that physical educators are more sensitive to the fragility of their adolescents students. But, the bottom line is that creating a curriculum that will improve cardiorespiratory fitness is fraught with challenges most school systems can’t address. It’s sad but true.

So, where does that leave us? This new study from England may be helpful for families who are caught in a time crunch and looking improve their fitness or for the physical educator who would like to help his/her motivated students get on a healthier track. But, this study should not prompt us to throw up our hands and toss out the current recommendations of an hour of moderate activity. As unrealistic as it may be for most school systems it allows for the injection of physical activity into academic settings where creative educators can offer things like walking lectures and field trips. It all boils down to the fact that some activity is better than none at all with or without the sweat equity.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

It’s no secret that the fitness level of all age groups in our country is poor. A recent study in Pediatrics sharpens the focus on the question of how we might address the problem in the teenage population. Based in England, the investigators placed wrist accelerometers on their 13- and 14-year-old subjects who were then assessed using shuttle runs at progressively faster speeds.

The researchers found that the participants’ cardiorespiratory fitness improved as the subjects’ time doing vigorous activity increased up to 20 minutes and then plateaued. The study authors could not prove that the vigorous activity caused the increased in fitness. However, they were impressed by the plateau phenomenon and suggest that this might suggest a change in the recommendations by the World Health Organization and U.S. Department of Health & Human Services which currently call for 60 minutes of moderate to vigorous physical activity per day for adolescents

At first blush a shift down to 20 minutes of vigorous activity would appear to be workable and achievable. This would be particularly true for public school systems that are already struggling to get any kind of activity shoehorned into their schedules that are already crammed in an attempt to address mandated academic achievement goals. Freeing up an additional 40 minutes of the school day and yielding improved cardiorespiratory fitness sounds like a win-win.

But, let’s take a deep breath and for a few moments return to the world of reality. First, how many school systems are providing that 60 minutes of moderate activity (let’s forget the vigorous piece for the moment) included in the current WHO/HHS recommendations? Next, let’s take a look at what “vigorous” activity means. There are variety of definitions but in general they include sweating, flushing, and dyspnea to the point of having difficulty speaking.

Let’s just focus on the “sweating” part. To me that sounds like an activity that would require some wardrobe alteration at a minimum and very likely a locker room and a shower. Those can be fightin’ words for many teenagers. Even if a school can provide adequate locker room and shower infrastructure change-ups and showers are time-gobbling activities. And, more realistically, what are the chances of getting body image–challenged adolescents to willingly take advantage of them? You don’t have to talk to very many adults before you will hear stories of discomfort and embarrassment resulting from forced locker room and shower experiences. When I was a teenager the only way you could flunk physical education was to refuse to go in the locker room and “change up.” I think or at least hope that physical educators are more sensitive to the fragility of their adolescents students. But, the bottom line is that creating a curriculum that will improve cardiorespiratory fitness is fraught with challenges most school systems can’t address. It’s sad but true.

So, where does that leave us? This new study from England may be helpful for families who are caught in a time crunch and looking improve their fitness or for the physical educator who would like to help his/her motivated students get on a healthier track. But, this study should not prompt us to throw up our hands and toss out the current recommendations of an hour of moderate activity. As unrealistic as it may be for most school systems it allows for the injection of physical activity into academic settings where creative educators can offer things like walking lectures and field trips. It all boils down to the fact that some activity is better than none at all with or without the sweat equity.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

It’s no secret that the fitness level of all age groups in our country is poor. A recent study in Pediatrics sharpens the focus on the question of how we might address the problem in the teenage population. Based in England, the investigators placed wrist accelerometers on their 13- and 14-year-old subjects who were then assessed using shuttle runs at progressively faster speeds.

The researchers found that the participants’ cardiorespiratory fitness improved as the subjects’ time doing vigorous activity increased up to 20 minutes and then plateaued. The study authors could not prove that the vigorous activity caused the increased in fitness. However, they were impressed by the plateau phenomenon and suggest that this might suggest a change in the recommendations by the World Health Organization and U.S. Department of Health & Human Services which currently call for 60 minutes of moderate to vigorous physical activity per day for adolescents

At first blush a shift down to 20 minutes of vigorous activity would appear to be workable and achievable. This would be particularly true for public school systems that are already struggling to get any kind of activity shoehorned into their schedules that are already crammed in an attempt to address mandated academic achievement goals. Freeing up an additional 40 minutes of the school day and yielding improved cardiorespiratory fitness sounds like a win-win.

But, let’s take a deep breath and for a few moments return to the world of reality. First, how many school systems are providing that 60 minutes of moderate activity (let’s forget the vigorous piece for the moment) included in the current WHO/HHS recommendations? Next, let’s take a look at what “vigorous” activity means. There are variety of definitions but in general they include sweating, flushing, and dyspnea to the point of having difficulty speaking.

Let’s just focus on the “sweating” part. To me that sounds like an activity that would require some wardrobe alteration at a minimum and very likely a locker room and a shower. Those can be fightin’ words for many teenagers. Even if a school can provide adequate locker room and shower infrastructure change-ups and showers are time-gobbling activities. And, more realistically, what are the chances of getting body image–challenged adolescents to willingly take advantage of them? You don’t have to talk to very many adults before you will hear stories of discomfort and embarrassment resulting from forced locker room and shower experiences. When I was a teenager the only way you could flunk physical education was to refuse to go in the locker room and “change up.” I think or at least hope that physical educators are more sensitive to the fragility of their adolescents students. But, the bottom line is that creating a curriculum that will improve cardiorespiratory fitness is fraught with challenges most school systems can’t address. It’s sad but true.

So, where does that leave us? This new study from England may be helpful for families who are caught in a time crunch and looking improve their fitness or for the physical educator who would like to help his/her motivated students get on a healthier track. But, this study should not prompt us to throw up our hands and toss out the current recommendations of an hour of moderate activity. As unrealistic as it may be for most school systems it allows for the injection of physical activity into academic settings where creative educators can offer things like walking lectures and field trips. It all boils down to the fact that some activity is better than none at all with or without the sweat equity.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

As a physician who has had a career-long obsession with the underappreciated value of sleep, a recent study published in the journal Child Development caught my eye. The findings presented by a group of Australian-based psychologists and educators suggest a positive association between napping and learning by preschool children. While the study itself relied on a very small sample and may not prove to be repeatable, the authors included in their introduction an excellent discussion of a large collection of recent studies supporting the educational benefit of sleep in general and napping in particular.

Although sleep seems to finally be receiving some of the attention it deserves, I am still concerned that as a profession we are failing to give it the appropriate weight at our health maintenance visits. This is particularly true of napping. Understandably, napping doesn’t feel urgent to parents in those turbulent first 4 or 5 months of night wakings and erratic settling. However, as a child approaches the 6-month milestone, napping is a topic ripe for well-considered anticipatory guidance.

When the recurrent cycles of awake-eat-sleep begin to develop into a somewhat predictable pattern and solid food is introduced, it’s time to suggest to parents a strategy that will encourage a napping pattern that will hopefully habituate into toddlerhood and beyond.

It can begin simply as a matter of defining the feeding in the middle of the day as lunch and then programming the period immediately following that meal as a siesta – a segment of the day completely reserved for rest. Many warm-weather countries have been using this strategy for centuries. Try to go to the pharmacy to pick up a prescription at 2 o’clock in the afternoon in rural Spain. It just ain’t gonna happen.

Most adults and children I know seem to be sleepy during this midday postprandial period. It makes more than a little sense to harness this natural drowsiness into creating a napping habit. However, the challenge for many young families is controlling their schedule to create a period of time when nothing else is going on in the child’s environment, leaving sleep as the only option. For some parents this requires the discipline to pause their own lives long enough so that the children realize that they aren’t missing out on something fun. This means no TV, no phone conversations, no visitors. Obviously, it also means not scheduling any appointments during this siesta period. Skilled day care providers have been doing this for years. But the message hasn’t seeped into the general population and sadly I occasionally see mothers with toddlers in the grocery store at 1 in the afternoon.

Once the nap/siesta is firmly welded to lunch, this gives the parent the ability to make minor adjustments that reflect the child’s stamina. If the child seems to be tiring/getting grumpy, serve up lunch a bit early and the restorative nap follows. As the child gets older and his or her stamina improves he or she may not be sleepy but the siesta remains as a quiet time. Some days it may be a nap, some days just a rest for an hour. By counseling parents to define the period after lunch as a siesta you will be helping them avoid that dreaded transition period called “giving up the nap.”

You may already be including this strategy in your anticipatory guidance. It may help to add to your advice the accumulating evidence that napping may play an important role in the child’s development and education.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

As a physician who has had a career-long obsession with the underappreciated value of sleep, a recent study published in the journal Child Development caught my eye. The findings presented by a group of Australian-based psychologists and educators suggest a positive association between napping and learning by preschool children. While the study itself relied on a very small sample and may not prove to be repeatable, the authors included in their introduction an excellent discussion of a large collection of recent studies supporting the educational benefit of sleep in general and napping in particular.

Although sleep seems to finally be receiving some of the attention it deserves, I am still concerned that as a profession we are failing to give it the appropriate weight at our health maintenance visits. This is particularly true of napping. Understandably, napping doesn’t feel urgent to parents in those turbulent first 4 or 5 months of night wakings and erratic settling. However, as a child approaches the 6-month milestone, napping is a topic ripe for well-considered anticipatory guidance.

When the recurrent cycles of awake-eat-sleep begin to develop into a somewhat predictable pattern and solid food is introduced, it’s time to suggest to parents a strategy that will encourage a napping pattern that will hopefully habituate into toddlerhood and beyond.

It can begin simply as a matter of defining the feeding in the middle of the day as lunch and then programming the period immediately following that meal as a siesta – a segment of the day completely reserved for rest. Many warm-weather countries have been using this strategy for centuries. Try to go to the pharmacy to pick up a prescription at 2 o’clock in the afternoon in rural Spain. It just ain’t gonna happen.

Most adults and children I know seem to be sleepy during this midday postprandial period. It makes more than a little sense to harness this natural drowsiness into creating a napping habit. However, the challenge for many young families is controlling their schedule to create a period of time when nothing else is going on in the child’s environment, leaving sleep as the only option. For some parents this requires the discipline to pause their own lives long enough so that the children realize that they aren’t missing out on something fun. This means no TV, no phone conversations, no visitors. Obviously, it also means not scheduling any appointments during this siesta period. Skilled day care providers have been doing this for years. But the message hasn’t seeped into the general population and sadly I occasionally see mothers with toddlers in the grocery store at 1 in the afternoon.

Once the nap/siesta is firmly welded to lunch, this gives the parent the ability to make minor adjustments that reflect the child’s stamina. If the child seems to be tiring/getting grumpy, serve up lunch a bit early and the restorative nap follows. As the child gets older and his or her stamina improves he or she may not be sleepy but the siesta remains as a quiet time. Some days it may be a nap, some days just a rest for an hour. By counseling parents to define the period after lunch as a siesta you will be helping them avoid that dreaded transition period called “giving up the nap.”

You may already be including this strategy in your anticipatory guidance. It may help to add to your advice the accumulating evidence that napping may play an important role in the child’s development and education.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

As a physician who has had a career-long obsession with the underappreciated value of sleep, a recent study published in the journal Child Development caught my eye. The findings presented by a group of Australian-based psychologists and educators suggest a positive association between napping and learning by preschool children. While the study itself relied on a very small sample and may not prove to be repeatable, the authors included in their introduction an excellent discussion of a large collection of recent studies supporting the educational benefit of sleep in general and napping in particular.

Although sleep seems to finally be receiving some of the attention it deserves, I am still concerned that as a profession we are failing to give it the appropriate weight at our health maintenance visits. This is particularly true of napping. Understandably, napping doesn’t feel urgent to parents in those turbulent first 4 or 5 months of night wakings and erratic settling. However, as a child approaches the 6-month milestone, napping is a topic ripe for well-considered anticipatory guidance.

When the recurrent cycles of awake-eat-sleep begin to develop into a somewhat predictable pattern and solid food is introduced, it’s time to suggest to parents a strategy that will encourage a napping pattern that will hopefully habituate into toddlerhood and beyond.

It can begin simply as a matter of defining the feeding in the middle of the day as lunch and then programming the period immediately following that meal as a siesta – a segment of the day completely reserved for rest. Many warm-weather countries have been using this strategy for centuries. Try to go to the pharmacy to pick up a prescription at 2 o’clock in the afternoon in rural Spain. It just ain’t gonna happen.

Most adults and children I know seem to be sleepy during this midday postprandial period. It makes more than a little sense to harness this natural drowsiness into creating a napping habit. However, the challenge for many young families is controlling their schedule to create a period of time when nothing else is going on in the child’s environment, leaving sleep as the only option. For some parents this requires the discipline to pause their own lives long enough so that the children realize that they aren’t missing out on something fun. This means no TV, no phone conversations, no visitors. Obviously, it also means not scheduling any appointments during this siesta period. Skilled day care providers have been doing this for years. But the message hasn’t seeped into the general population and sadly I occasionally see mothers with toddlers in the grocery store at 1 in the afternoon.

Once the nap/siesta is firmly welded to lunch, this gives the parent the ability to make minor adjustments that reflect the child’s stamina. If the child seems to be tiring/getting grumpy, serve up lunch a bit early and the restorative nap follows. As the child gets older and his or her stamina improves he or she may not be sleepy but the siesta remains as a quiet time. Some days it may be a nap, some days just a rest for an hour. By counseling parents to define the period after lunch as a siesta you will be helping them avoid that dreaded transition period called “giving up the nap.”

You may already be including this strategy in your anticipatory guidance. It may help to add to your advice the accumulating evidence that napping may play an important role in the child’s development and education.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Now hot off the press from the “always-guessed-it-was-true-but-now-you-know-it” department comes a multinational study that looked at childhood cardiovascular risk factors and longevity.

Using data collected from individuals in Finland, Australia, and the United States the International Childhood Cardiovascular Cohorts Consortium Outcomes Study investigators sought links between subjects’ body mass index, systolic blood pressure, total cholesterol, blood triglyceride level, and smoking in childhood with cardiovascular disease and outcomes as they aged into adulthood.

The children were initially enrolled in the 1970s and 1980s. The adult evaluations were done in 2015-2019 when the subjects’ average age was 46. Of the 40,000 individuals who originally entered the study, 800 were found to have cardiovascular events of which over 300 had resulted in death. I found these numbers a bit surprising given the relatively young age at which the follow-up data were collected.

What was less surprising is that people with higher than normal values for all five risk factors as children had nearly three times the risk of cardiovascular disease as adults. Researchers found that smoking at a young age was biggest risk factor with body mass index, systolic blood pressure, blood triglycerides, and cholesterol following in descending order. They also found that adults who were obese as children had triple the risk of cardiovascular disease as adults. High blood pressure in childhood doubled the risk.

It will be interesting to see if and how these trends change as the study population ages. It could be that the effect of these childhood risk factors is blunted as the those segments at the highest risk die off and/or risk- associated behaviors adopted in adulthood become more prominent. But, it feels more likely that the childhood risk factors will remain as major contributors.

Is this just another ho-hum-told-you-so study or does it have some special relevance for us as pediatricians? At a minimum these findings should inspire us to stick with our calling to commit ourselves to the health of children. A healthy adult population is clearly our legacy.

Of course the two individual risk factors in childhood that appear to be the most potent in adulthood, obesity and smoking, are also the most frustrating for pediatricians to address. However, the study suggests that we should rejoice in those few successes when we achieve them. Childhood obesity has been a tough nut to crack. On the other hand, the societal change that has made great strides in adult smoking over the last half century should encourage us that our work with the pediatric population will eventually bring rewards.

Smoking and obesity can include components of both patient and parental behavior. Monitoring cholesterol, triglycerides, and blood pressure hinges on our behavior as providers. Although there have been recent recommendations that we be more attentive, we don’t have a strong history when it comes to detecting and addressing high blood pressure in children. This study should serve as an another reminder to take blood pressure more seriously.

I was surprised and somewhat disappointed that I first learned about the results of this study in an email newsletter from the medical school I attended. I would have hoped that a paper like this from a well known peer-reviewed journal with a clear message about the relationship of childhood health and longevity should have been picked up quickly by the lay press. Again, this leaves it to us to promote the message that the health of children is important in and of itself but plays a critical role in the health of adults.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Now hot off the press from the “always-guessed-it-was-true-but-now-you-know-it” department comes a multinational study that looked at childhood cardiovascular risk factors and longevity.

Using data collected from individuals in Finland, Australia, and the United States the International Childhood Cardiovascular Cohorts Consortium Outcomes Study investigators sought links between subjects’ body mass index, systolic blood pressure, total cholesterol, blood triglyceride level, and smoking in childhood with cardiovascular disease and outcomes as they aged into adulthood.

The children were initially enrolled in the 1970s and 1980s. The adult evaluations were done in 2015-2019 when the subjects’ average age was 46. Of the 40,000 individuals who originally entered the study, 800 were found to have cardiovascular events of which over 300 had resulted in death. I found these numbers a bit surprising given the relatively young age at which the follow-up data were collected.

What was less surprising is that people with higher than normal values for all five risk factors as children had nearly three times the risk of cardiovascular disease as adults. Researchers found that smoking at a young age was biggest risk factor with body mass index, systolic blood pressure, blood triglycerides, and cholesterol following in descending order. They also found that adults who were obese as children had triple the risk of cardiovascular disease as adults. High blood pressure in childhood doubled the risk.

It will be interesting to see if and how these trends change as the study population ages. It could be that the effect of these childhood risk factors is blunted as the those segments at the highest risk die off and/or risk- associated behaviors adopted in adulthood become more prominent. But, it feels more likely that the childhood risk factors will remain as major contributors.

Is this just another ho-hum-told-you-so study or does it have some special relevance for us as pediatricians? At a minimum these findings should inspire us to stick with our calling to commit ourselves to the health of children. A healthy adult population is clearly our legacy.

Of course the two individual risk factors in childhood that appear to be the most potent in adulthood, obesity and smoking, are also the most frustrating for pediatricians to address. However, the study suggests that we should rejoice in those few successes when we achieve them. Childhood obesity has been a tough nut to crack. On the other hand, the societal change that has made great strides in adult smoking over the last half century should encourage us that our work with the pediatric population will eventually bring rewards.

Smoking and obesity can include components of both patient and parental behavior. Monitoring cholesterol, triglycerides, and blood pressure hinges on our behavior as providers. Although there have been recent recommendations that we be more attentive, we don’t have a strong history when it comes to detecting and addressing high blood pressure in children. This study should serve as an another reminder to take blood pressure more seriously.

I was surprised and somewhat disappointed that I first learned about the results of this study in an email newsletter from the medical school I attended. I would have hoped that a paper like this from a well known peer-reviewed journal with a clear message about the relationship of childhood health and longevity should have been picked up quickly by the lay press. Again, this leaves it to us to promote the message that the health of children is important in and of itself but plays a critical role in the health of adults.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Now hot off the press from the “always-guessed-it-was-true-but-now-you-know-it” department comes a multinational study that looked at childhood cardiovascular risk factors and longevity.

Using data collected from individuals in Finland, Australia, and the United States the International Childhood Cardiovascular Cohorts Consortium Outcomes Study investigators sought links between subjects’ body mass index, systolic blood pressure, total cholesterol, blood triglyceride level, and smoking in childhood with cardiovascular disease and outcomes as they aged into adulthood.

The children were initially enrolled in the 1970s and 1980s. The adult evaluations were done in 2015-2019 when the subjects’ average age was 46. Of the 40,000 individuals who originally entered the study, 800 were found to have cardiovascular events of which over 300 had resulted in death. I found these numbers a bit surprising given the relatively young age at which the follow-up data were collected.

What was less surprising is that people with higher than normal values for all five risk factors as children had nearly three times the risk of cardiovascular disease as adults. Researchers found that smoking at a young age was biggest risk factor with body mass index, systolic blood pressure, blood triglycerides, and cholesterol following in descending order. They also found that adults who were obese as children had triple the risk of cardiovascular disease as adults. High blood pressure in childhood doubled the risk.

It will be interesting to see if and how these trends change as the study population ages. It could be that the effect of these childhood risk factors is blunted as the those segments at the highest risk die off and/or risk- associated behaviors adopted in adulthood become more prominent. But, it feels more likely that the childhood risk factors will remain as major contributors.

Is this just another ho-hum-told-you-so study or does it have some special relevance for us as pediatricians? At a minimum these findings should inspire us to stick with our calling to commit ourselves to the health of children. A healthy adult population is clearly our legacy.

Of course the two individual risk factors in childhood that appear to be the most potent in adulthood, obesity and smoking, are also the most frustrating for pediatricians to address. However, the study suggests that we should rejoice in those few successes when we achieve them. Childhood obesity has been a tough nut to crack. On the other hand, the societal change that has made great strides in adult smoking over the last half century should encourage us that our work with the pediatric population will eventually bring rewards.

Smoking and obesity can include components of both patient and parental behavior. Monitoring cholesterol, triglycerides, and blood pressure hinges on our behavior as providers. Although there have been recent recommendations that we be more attentive, we don’t have a strong history when it comes to detecting and addressing high blood pressure in children. This study should serve as an another reminder to take blood pressure more seriously.

I was surprised and somewhat disappointed that I first learned about the results of this study in an email newsletter from the medical school I attended. I would have hoped that a paper like this from a well known peer-reviewed journal with a clear message about the relationship of childhood health and longevity should have been picked up quickly by the lay press. Again, this leaves it to us to promote the message that the health of children is important in and of itself but plays a critical role in the health of adults.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

I suspect that you have heard or read about the recent study in the Journal of Neuroscience that claims to have discovered evidence that as children become teenagers, their brains begin to tune out their mother’s voices. The story appeared in at least 10 Internet news sources including the American Academy of Pediatrics’ daily briefing.

Based on functional MRI studies by a group at Stanford (Calif.) University, the researchers found that while in general, teenagers became more attentive to all voices as they reached puberty, novel voices were favored over the maternal voices that had flooded their environment as younger children. Of course none of this comes as a surprise to anyone who has parented a teenager or spent any time trying to communicate with adolescents. Although we all must be a bit careful not to put too much stock in functional MRI studies, these findings do suggest a physiologic basis for the peer pressure that becomes one of the hallmarks of adolescence. I wouldn’t be surprised if some clever entrepreneur has already begun using MRI to search for just the right tonal qualities that will make the perfect Internet influencer.

But, will these MRI studies help parents who have already thrown up their arms and admitted defeat mumbling, “He’s stopped listening to me?” The more observant parents already realized long ago that their words were often the least effective tools in their tool kit when it comes to modifying behavior.

Just listen in any neighborhood playground or grocery store to how often you hear a parent trying to get a toddler or young child to correct a misbehavior using threats or promises that you and everyone else within earshot knows will never be followed by any consequence. How often do you see a parent modeling behaviors that they expect their children to avoid?

Some more “enlightened” parents will avoid threats and instead attempt to engage in a dialogue with their misbehaving child hoping that a rational discussion with a sleep-deprived toddler in full tantrum mode can convince the youngster to self-correct.

I’m sure you learned and may have even used the playground retort “sticks and stones may break my bones but words will never hurt me.” Of course more untrue words were never spoken. Words can hurt and they can scar. But words and threats can also be hollow and will fall on ears deafened by months and years during which there were no consequences. It is certainly nice to know that there is some physiologic correlation to what we all suspected. The good news is that teenagers are still listening to us, although they are increasingly more interested in what their peers and the rest of the world has to say.

What the study fails to point out is that while teenagers may still be listening to us their behavior is molded not so much by what we say but how we as parents and adults behave. Have we parented in a way in which our words are followed up with appropriate consequences? And, more importantly, have we modeled behavior that matches our words? We need to help parents realize that words can be important but parenting by example is the gold standard.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

I suspect that you have heard or read about the recent study in the Journal of Neuroscience that claims to have discovered evidence that as children become teenagers, their brains begin to tune out their mother’s voices. The story appeared in at least 10 Internet news sources including the American Academy of Pediatrics’ daily briefing.

Based on functional MRI studies by a group at Stanford (Calif.) University, the researchers found that while in general, teenagers became more attentive to all voices as they reached puberty, novel voices were favored over the maternal voices that had flooded their environment as younger children. Of course none of this comes as a surprise to anyone who has parented a teenager or spent any time trying to communicate with adolescents. Although we all must be a bit careful not to put too much stock in functional MRI studies, these findings do suggest a physiologic basis for the peer pressure that becomes one of the hallmarks of adolescence. I wouldn’t be surprised if some clever entrepreneur has already begun using MRI to search for just the right tonal qualities that will make the perfect Internet influencer.

But, will these MRI studies help parents who have already thrown up their arms and admitted defeat mumbling, “He’s stopped listening to me?” The more observant parents already realized long ago that their words were often the least effective tools in their tool kit when it comes to modifying behavior.

Just listen in any neighborhood playground or grocery store to how often you hear a parent trying to get a toddler or young child to correct a misbehavior using threats or promises that you and everyone else within earshot knows will never be followed by any consequence. How often do you see a parent modeling behaviors that they expect their children to avoid?

Some more “enlightened” parents will avoid threats and instead attempt to engage in a dialogue with their misbehaving child hoping that a rational discussion with a sleep-deprived toddler in full tantrum mode can convince the youngster to self-correct.

I’m sure you learned and may have even used the playground retort “sticks and stones may break my bones but words will never hurt me.” Of course more untrue words were never spoken. Words can hurt and they can scar. But words and threats can also be hollow and will fall on ears deafened by months and years during which there were no consequences. It is certainly nice to know that there is some physiologic correlation to what we all suspected. The good news is that teenagers are still listening to us, although they are increasingly more interested in what their peers and the rest of the world has to say.

What the study fails to point out is that while teenagers may still be listening to us their behavior is molded not so much by what we say but how we as parents and adults behave. Have we parented in a way in which our words are followed up with appropriate consequences? And, more importantly, have we modeled behavior that matches our words? We need to help parents realize that words can be important but parenting by example is the gold standard.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

I suspect that you have heard or read about the recent study in the Journal of Neuroscience that claims to have discovered evidence that as children become teenagers, their brains begin to tune out their mother’s voices. The story appeared in at least 10 Internet news sources including the American Academy of Pediatrics’ daily briefing.

Based on functional MRI studies by a group at Stanford (Calif.) University, the researchers found that while in general, teenagers became more attentive to all voices as they reached puberty, novel voices were favored over the maternal voices that had flooded their environment as younger children. Of course none of this comes as a surprise to anyone who has parented a teenager or spent any time trying to communicate with adolescents. Although we all must be a bit careful not to put too much stock in functional MRI studies, these findings do suggest a physiologic basis for the peer pressure that becomes one of the hallmarks of adolescence. I wouldn’t be surprised if some clever entrepreneur has already begun using MRI to search for just the right tonal qualities that will make the perfect Internet influencer.

But, will these MRI studies help parents who have already thrown up their arms and admitted defeat mumbling, “He’s stopped listening to me?” The more observant parents already realized long ago that their words were often the least effective tools in their tool kit when it comes to modifying behavior.

Just listen in any neighborhood playground or grocery store to how often you hear a parent trying to get a toddler or young child to correct a misbehavior using threats or promises that you and everyone else within earshot knows will never be followed by any consequence. How often do you see a parent modeling behaviors that they expect their children to avoid?

Some more “enlightened” parents will avoid threats and instead attempt to engage in a dialogue with their misbehaving child hoping that a rational discussion with a sleep-deprived toddler in full tantrum mode can convince the youngster to self-correct.

I’m sure you learned and may have even used the playground retort “sticks and stones may break my bones but words will never hurt me.” Of course more untrue words were never spoken. Words can hurt and they can scar. But words and threats can also be hollow and will fall on ears deafened by months and years during which there were no consequences. It is certainly nice to know that there is some physiologic correlation to what we all suspected. The good news is that teenagers are still listening to us, although they are increasingly more interested in what their peers and the rest of the world has to say.

What the study fails to point out is that while teenagers may still be listening to us their behavior is molded not so much by what we say but how we as parents and adults behave. Have we parented in a way in which our words are followed up with appropriate consequences? And, more importantly, have we modeled behavior that matches our words? We need to help parents realize that words can be important but parenting by example is the gold standard.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].