June 28, 2009

Fluoride


Conspiracy theories have an origin somewhere. Maybe there is a morsel of fact that starts them, or maybe it's just an individual person someplace. How do they take hold? It's safe to suspect that most of them never get any traction and just fade away.

The following dialog is from one of my favorite movies, Dr. Strangelove (directed by Stanley Kubrick in 1964). The troubled General Ripper (played by Sterling Hayden) is talking to Captain Mandrake (Peter Sellers) .
Ripper: Mandrake. Mandrake, have you never wondered why I drink only distilled water, or rain water, and only pure-grain alcohol?
Mandrake: Well, it did occur to me, Jack, yes.
Ripper: Have you ever heard of a thing called fluoridation. Fluoridation of water?
Mandrake: Uh? Yes, I-I have heard of that, Jack, yes. Yes.
Ripper: Well, do you know what it is?
Mandrake: No, no I don’t know what it is, no.
Ripper: Do you realize that fluoridation is the most monstrously conceived and dangerous Communist plot we have ever had to face?





Fluoride does, by the way, prevent cavities. Generally, municipalities aim for a level of fluoride in the drinking water of about 1mg per liter. In some areas, often mountain or volcanic areas (like much of the western U.S.), well water can contain many times this amount, even 50mg/L. (The makers of bottled water are under no obligation to report if the water contains any fluoride or too much.) It's hard to imagine that communists, wherever they may be, are conspiring to bring to some areas of the country what other areas have had naturally for generations.

Fluoride helps to form really tough tooth enamel that is resistant to bacterial attack, resulting in less tooth decay and fewer cavities. It's very effective, and reduces cavities by somewhere between 20% and 60%.

You can get too much, however. If too much is consumed all at once, fluoride can cause nausea, diarrhea, and vomiting. This happened in a village in Alaska in 1993, when water levels were 150mg/L.

In many areas of China, natural fluoridation of the water, from rock in the ground, keeps water levels about what we usually get in our tap water. It's often in coal, and in the city of Sichuan, there's enough coal pollution in the air so that just by breathing, people there get many times our usual daily dose of fluoride.

When children between 1 and 4 have too much fluoride, they can develop teeth with brownish stains. Children over 8 are not at risk for this.

Since we are not meant to swallow toothpaste, it has a fluoride concentration much higher than our drinking water. It's not toxic as long as we don't eat the whole tube.

At some point, a now-wealthy entrepreneur invented delicious, candy-flavored toothpaste for kids. They willingly brushed their teeth. Then, when their parents weren't looking, they snuck into the bathroom and ate the whole tube. So fluoride is no longer in children's toothpaste. But they still want to eat the whole tube. So I think the right idea is for you to dispense the toothpaste for them, and keep the tube with your medications, in a secure place.

Babies, especially as their teeth start coming in, don't need any kind of toothpaste. Clean their teeth with a clean cloth moistened with water.

And every child should go to the dentist. I strongly encourage parents to take them to the dentist when they are well, so the child can see what the place is like and what the exam is about. After that, there's a better chance that if they need dental work, it won't be too scary.







The mineral crystals pictured at top are Calcium Fluorite. The glowing thing on the left, below it, is also Fluorite but viewed under untraviolet light. This is the origin of the word fluorescent.

June 25, 2009

Squirmy


When I heard that the baby was 'thrashing around' and crying, I didn't know what to make of it. Her father said that she had a rash, and he wondered if this new behavior was related.

Here's a tip: don't ask the doctor, 'what could it be?' I have whole textbooks filled with awful diseases that your child doesn't have and won't get. Try to focus on what they do have. But an important part of my job is indeed to worry about what a problem could be. So during the phone conversation with the baby's father, I thought of the possibilities. These included everything from using the wrong detergent on her onesies to serious illnesses with seizures. Though I was reassured by some basic screening questions over the phone, I decided to see the baby in person that night. It was Saturday on a 3-day Memorial Day Weekend, and I didn't want to wait until Tuesday when the office was scheduled to open. The baby was only 2 months old.

When I got to the house, the baby's parents gave me more history. They said that this has been going on for about a week. She didn't have fever or any other symptoms of being sick. They noticed a couple of rough patches on her skin which they have been treating with a calendula cream. Over the week, despite more frequent treatment with the calendula cream, the rash has been getting much worse and more widespread over her body.

I felt the rash, which covered her forehead and cheeks, behind her ears, her elbows and lower legs, and had patches all over her body. She had eczema. In older kids, eczema typically affects different places on the body than it does on babies. Her places and the appearance and feel of the rash were characteristic of eczema for kids her age.

Eczema seems to travel genetically with allergies and asthma. Sometimes a parent will have one of these and the child will have another or some combination. In this case, the father said that he had eczema as a child and the mother had a little eczema now.

But I wondered what caused it to erupt so suddenly. Though eczema usually goes through times of improvement and worsening, these don't usually happen in just a few days. I had seen the baby in my office about 2 weeks earlier, and the parents didn't mention it and I didn't notice it. I asked them to tell me about absolutely everything they put on the baby's skin. It made my job a little easier when they showed me the product. It was very expensive, and from a very successful all-natural, organic, line of 'Natural Medicines.' (Except for removing the actual brand name, the following is an exact quote from the company's description of the product.)

"Brand Name® Calendula Cream is excellent for use on general diaper area, cradle cap, on cuts and scrapes, and may be used on face and body for extra-dry or sensitive skin. Botanically based, our light and fluffy Calendula Cream contains the active ingredient of Calendula, which has been used to heal the skin for centuries. Brand Name® Calendula Cream offers deep hydration, absorbs completely, and leaves skin feeling satiny smooth. Use daily for everyday protection and especially when the air is dry and baby's skin needs relief. Our customers have reported excellent results with Brand Name®'s Calendula Cream in their fight against eczema, perioral dermatitis, and other skin sensitivities. The entire family can benefit from this soothing, multipurpose cream. We suggest that you try Brand Name® Calendula Cream and/or Brand Name® Botanical Moisturizing Cream in combination with any of our Shampoos & Bodywashes. Also add Brand Name® Calming™ Soothing & Healing Spray, and any of our non-chemical sunscreens to your skin care regime.
  • Contains organic and sustainably grown ingredients
  • Active ingredient: Calendula officinalis is the common pot marigold and is well known for its skin healing properties
  • Safe, gentle and effective for cuts, sores and general skin abrasions
  • May be used around the diaper area for simple rashes
  • Hypo-allergenic
  • Works very well on cradle cap and chapped skin
  • Light and fluffy consistency"

What, exactly, does 'hypo-allergenic' mean? I certainly don't know in the context of any calendula product. Calendula is from marigold flowers. Marigolds are in the same family as ragweed, which is probably the most common pollen that people are allergic to, maybe as much as 10-20% of all Americans. This has been studied. In about 2% of people, using calendula on the skin causes an eczema-like rash.

The poor baby was suffering and itchy. I sent a parent out immediately to get some medicated cream that I hoped would start helping her feel better right away. Within a couple of days of stopping the calendula and starting some very low-strength medicated cream, the rash was nearly gone and the thrashing had stopped.

Except to instruct the parents to stop using the calendula and stick to the regular medicated cream right now, I didn't say anything about the product they had been using. It wasn't their fault that the label does more than imply—it states quite clearly—that the product is hypoallergenic and safe to use. And I wondered why they let this rash spread and grow along with their baby's discomfort as they used something, though with the best of intentions, that was clearly not working. If I had prescribed a cream for the baby which was clearly not working, and the baby was getting worse and worse, would they have continued using it for a week? Would they have called me after a day or two, concerned? What were their expectations for this product? Why did they wait until the baby had such a severe, extensive and obvious rash? What was there about this product that allowed them to tolerate its ineffectiveness much longer than I suspect they would have tolerated a prescription product?

The rapid worsening and extension of the baby's rash, I believe, was the result of a reaction to the calendula. It's common enough (about 1 in every 50 people) that I think it should be a caution on the label. Especially because it's intended use is for the very rash that it causes. Because it's sold as a natural supplement, the manufacturer doesn't have to do this.

This may or may not be related to the Bollywood version.

June 22, 2009

The Really Dark Places

Every parent knows what the really dark places are. Nobody goes there.

There are aspects of postpartum depression that each parent keeps unsaid. These thoughts become more prominent as their sleep deprivation becomes more profound. But irrational thoughts are vulnerable to the bright light of day. In my approach to postpartum depression, I want the parent to voice these secret fears, so that I can share the burden of them if necessary, and deal with them openly. After all, it worked with a 9-year-old in Dark Places.

The first time a mother told me that she was afraid of going to sleep, I didn't know how to react. She had just brought the baby home from the hospital and though the baby was healthy in every way, she was afraid that the baby would stop breathing. Her husband tried to convince her that the baby would most likely be fine, but she told me she didn't trust his judgement on this. While she was up in the middle of the night, she got on the internet and learned about apnea monitors that sound an alarm if the baby stop breathing for some length of time. She requested a prescription for one of these. Her husband called a day later and told me that now she didn't want to put the baby down. I went to their apartment.

Mom cried when I arrived because she felt safer. I asked how the baby was doing, and she burst into tears again as she said that the baby was doing very well. When I told her I was not going to prescribe the alarm she wanted, she cried about that, too.

This mother was suffering. In most families with a newborn, there's a mixture of bliss and exhaustion. She was not enjoying much from her child.

I knew that there wasn't much I could do to improve this healthy baby. But I could, one by one, hold each one of her fears up to the light and defuse its power by giving the mother a lot of information and a sense of control. Her darkest place was SIDS.

This is a difficult, nearly taboo, topic to write about and a difficult one for a parent to read about. But again and again I am impressed with the power of knowledge to drain the potency from irrational fears. So here goes.

A recent study looked at all SIDS cases in Germany over 3 years. (Their experience is very similar to the U.S.) There were a lot of statistics, but taking most things into account, the scientists calculated the risk added by different factors. In this type of analysis, the baseline risk is set at 1.00 (it'll be clearer in a moment). In Germany, there's 40 cases of SIDS in every 100,000 live births. In the U.S., there's 54 cases in every 100,000. So it's a little more common in the U.S., but not a lot more. It is very rare. This is the baseline risk. The 'odds ratio' for this is 1.00.

  • If there's a pillow in the infant's bed, the risk is higher: odds ratio 1.03.
  • If the baby is not breastfeeding, the risk is higher: odds ratio 1.71.
  • If the parents and baby are bed sharing: odds ratio 2.71.
  • If the mother smoked during pregnancy: odds ratio 3.43.
  • If the baby was put to sleep on its tummy: odds ratio 6.08.
  • If the mother was less than 20 years old at delivery: odds ratio 18.71.
  • If the baby slept in the bedroom at a friend's place: odds ratio 38.67.
  • If family used a pacifier for the baby: odds ratio 0.40.

This is how I interpret the odds ratios. If the mother smoked during pregnancy, there's about triple the risk of SIDS. If the baby was put to sleep on her tummy, there's about 6 times the risk. If the mother is a teen mom, there's almost 20 times the risk. And there's almost 40 times the risk when mom and baby spend the night at a friend's. And using a pacifier regularly seems to reduce the risk to less than half of the baseline risk.




Some of these make sense. Maternal smoking might have an impact on the baby's breathing or even their brain chemistry. I can only guess that teenage mothers, compared with more mature mothers, might not be as good at planning or making careful, well thought-out decisions.

I don't know why pacifier use seems to be a little protective. Several studies have confirmed this finding in the United States and elsewhere. Maybe the babies are calmer?

The one that I know will be controversial is co-sleeping. The babies like it and the parents like it. It's very conducive to easy nursing in the night. But make no mistake, many studies confirm that it nearly triples the risk to the baby.

The hard part for us all is digesting and processing very small risks. Everyone who lives in the San Francisco Bay area knows that there is some risk of a major earthquake. If it comes at the wrong moment, the consequences for each of us could be severe. We don't know exactly what those odds are, but they are pretty low. We manage the multitude of little risks every day. The risk of a serious accident, building collapse, asteroid impact. People with anxiety disorders have difficulty ignoring many of these very rare risks and are sometimes trapped by their fears.

I had a piece of paper and had this mother dictate to me a specific list. We went through the list item by item. It made her feel better.

June 19, 2009

The Dark Places

Everybody has dark places that they just don't want to go. Sometimes these places are physical locations that we can't avoid.

Evelyn is 9 and has asthma. Controlling her symptoms has been challenging, not because her asthma is so severe, but because her family is very disorganized. As with most chronic conditions, steady routines of preventive care can help to avoid serious episodes. On one Sunday, she was having particular difficulty, so I went to her home to check on her. She turned out basically to be OK and she and her family just needed some hands-on coaching to remind them when and how to use which medication.

A house call is a powerful tool, neither taught nor mentioned in medical training. I have learned a lot from them, and the information from experiencing a child's home is much more substantial than can be inferred from a brief history provided in an office visit. This is particularly true for chronic disease.

Evelyn was eager to show me her room. Her bed was completely hidden under an army of stuffed animals that covered it entirely. There were many clothes on the floor, some clean and some not. There was no door on her closet. She had a desk, which was cluttered with piles of books. Dust was thick everywhere. It looked like nobody in the family was a good housekeeper. I asked her, hinting at the stuffed animals, where her bed was. She pointed to the bed and added, “But I don't sleep there.”

She slept nearly every night on the sofa in the equally dusty living room. I asked, of course, why.

She was afraid of spiders, she explained, as if I were somehow inexplicably dense and couldn't see the obvious.

Evelyn knew there were cobwebs in the corners of her room, and her fear of spiders prevented her from turning off the light when she was in the room. The usual age for the start of specific phobias was about 7, and she said she'd been very afraid of them for a couple of years. She denied any specific traumatic experience, though.

Fear of spiders is one of the most common phobias, and it seems that this affects girls more frequently than boys. But phobias are very common, and we often are embarrassed by them and don't talk about them—we just plan our activities to avoid confronting them. So often when I diagnose an anxiety disorder, I find that the child has specific phobias they never told anyone about. They know that these phobic feelings are not shared by their friends, and sometimes they aren't even comfortable sharing with their parents. Even if the phobias aren't something that restricts their daily life, the child can feel deeply ashamed of what they know is an abnormal perception. So when I am talking to a child who I think might have an anxiety disorder, I always ask about phobias. And when a parent mentions to me that their child has not one but several phobias, I always will consider anxiety.

The key to her asthma control was getting her a low-dust place to sleep, so I offered to come and clean her room with her. She liked this idea and so did her mom. I told them to buy plastic storage bins big enough for clothes and toys, and asked her mother to sew a curtain-rod-to-floor washable curtain to use instead of a closet door. When I returned about a week later, all but one stuffed animal was in a bin. She was welcome to take all of them out whenever she liked, but she could only sleep with one. All the books went in a bin. The clothes went either into a laundry bag in the now-closed closet, or into a bin if clean. Evelyn herself was to take a damp sweeper/mop and dust her bare floor every day. I had a hidden purpose when I proposed this. Sure, it kept the dust level low in her room, which I hoped would help her asthma control. But it gave her control of the corners of her room. By cleaning them herself every day (they shouldn't get too dirty in just a day), she would be reminded that they are really clean, really empty, with no webs or spiders to lurk in the dark.

There was a lot of sneezing while we were cleaning the little room, but we ended up with a lot of dustable smooth surfaces (the floor, the desk, the lids on the bins) that could be kept clean with minimal effort. Within a few weeks, her asthma was much less of a problem. She was still afraid of spiders, but since she herself (with me there helping and protecting her) had cleaned out those dark corners, she could rest much easier in her own bed. I slept better too.

June 16, 2009

Talk to Me


The Allens came to my office looking for a different approach. Alice, their first baby, had been born 6 months earlier, and, they admitted, things weren't going well. They had a hard time articulating the problem, however. Somehow, they just weren't enjoying the experience of parenthood. Why weren't having a good time with their baby the way other people usually do? Was there something wrong with the baby? Was there something wrong with them?

They liked their last pediatrician. When they brought up their vague reservations, she tried to be reassuring, but it just didn't take. The doctor visits were generally brief, and this hazy discomfort was never really focused on.

Baby Allen was a sweet girl with big eyes who smiled at me during her exam. She was growing and developing normally, and had never been sick. She was making some sounds in the stroller, but the parents didn't respond.

“Ack?” she asked when I picked her up. Professional that I am, I knew the answer.

“Ack,” I said.

“Ack,” she repeated, continuing the conversation.

“Ack,” I said, since I wanted to continue too. She paused for a moment.

“Ack?” she asked again, obviously giving further consideration to her earlier question.

“Ack,” I responded, with a big smile. She gave me a big smile in return, which turned into a laugh. The conversation continued for at least 4 or 5 minutes.

Her parents watched the exchange in amazement. It was clearly, obviously, a conversation. She changed her tone of voice as if to convey meaning, so sometimes the same limited sound was a question and sometimes a statement or a surprise. “Haven't you guys ever done that?” I asked them. They said they didn't know she could do that. “How much do you talk to her?” They looked at each other quizzically. I saw where this was going.

What I was doing, fundamentally, was letting the baby steer the conversation. More importantly, it was listening to the baby and allowing her to be in charge. I think of this as an empathic approach, which is applicable to children of all ages. Listen to your children, take wht they say seriously, and, whenever you can, let them lead you.

It turns out that talking to your baby is incredibly important. Though research has barely started on the real impact of these kind of interactions, babies consistently surprise us with the things they can do.

So it didn't surprise me when I read a study, just published, about the conversations of 5-month-olds. They videotaped 37 babies interacting with adults the babies didn't know. The scientists watched what happened to the vocalizations of the babies when the adult made a blank face. Sure enough, the babies stopped their sounds when they got the blank face but continued when they got smiles. Think about this. By the time babies are 5-months old, they have learned how to control at least this aspect of the behavior of their caregivers. From this experiment (and others) we know that babies actively learn what to do by experimenting on us. And what you might not expect is that when these scientists followed up with the babies they studied, they found that the strength of their skills at 5 months predicted their language skills at 13 months. I wonder if there are babies born with great language skills, or if the constant practice of having a caregiver talk to them and with them gives them extra practice and maybe even stimulates the language center of their brains and helps it develop.

Would it help to have a translator for a baby's grunts or cries? This will be the topic of an upcoming post.

I sent this family home with an exercise prescription. I told them not to miss an opportunity to talk to their baby, even read to the baby. It was OK if they read her the newspaper or a magazine.

There was a secret agenda. Empathy, the ability to understand what another person is feeling, is absolutely crucial to successful relationships with others. That includes conversations with babies and complex social skills. The baby will benefit from more interactions with her parents. She will learn to listen and respond, maybe how to initiate and manage a social interaction. She will learn that her parents are interested in what she has to say. But I believed the parents will get a lot out of it too. They'll experience the great things their baby can do and the many ways she will reach out to them.


Epilogue--The prescription really worked! A few weeks later they reported that things have never been better with the baby and between themselves. They each try to outdo the other in how long and complex they can make their infant conversations. They told me that the baby has never laughed so much. Them, too.


The photograph above is from my collection and is by Lewis Carroll.



June 13, 2009

Claire 7: Fossil


When Claire had her first lesson in self-hypnosis, the goal was for her to learn how to concentrate on relaxation, and push her anxieties aside for the moment. I gave her a homework assignment—to practice this at night when she was having trouble falling asleep because of her rushing thoughts.

But I wanted to help her find a way to use this to help her with the anxiety-provoking situations that she confronts many times during an average day. With me guiding her, and her mother in the room, and it’s quiet and comfortable, the task of concentrating and walking herself through the relaxation protocol is much easier. For someone who is generally distractible, going through these same steps in a noisy busy environment can be much more difficult.


I went to an unusual store that sells skeletons and fossils and crickets to feed your lizard. The crickets are loud! I bought her a small polished rock with a little ammonite fossil, pictured above. It’s very smooth. I gave it to her.

We went through the same process, starting with tensing her toes then relaxing them. Then did this ascending through the muscles of her body. Then the warm pool from the sole of her feet to her neck. I suggested that she feel the smooth stone, rub it in her fingers. I suggested that it would remind her of her feeling of relaxation and of the things that made her confident: the studying that she did, the many people who love her. This feeling right now of comfort and freedom from worry could come to her when she holds this stone.

I’ve used a little fossil stone several times with children, and I always have one or two on hand for just this use. It’s smooth and not dangerous to handle or keep in your pocket. It’s not loaded with other potential issues like a religious symbol—though these can be used for the same purpose if the child is into it and if the thing is new to them. And it isn’t going to be a trigger for other kids to make fun of. Worry beads, good luck charms of all kinds, even rosaries may have powerful influences, but for a particularly anxious child to whom fitting in is so important, having something that doesn’t draw unusual attention is good. Besides, who doesn’t like fossils? If a classmate sees it, my patient doesn’t have to hesitate to show it off to others. It’s a cool thing.

The plan is for her to have it in her pocket, where she can touch it whenever she needs to, during a test or when talking to friends or even boys. It's just a reminder, something tangible, of a different state of mind.

What does it really do? A sensory experience such as a smell or a few notes of music can trigger an involuntary memory, and those memories can bring with them the feelings associated with those experiences. What I've tried to do is create a carefully designed memory of a new, relaxing experience without being tainted by anxiety. Then the stone can, on demand, be a trigger for a memory that brings with it the feeling of comfort and confidence.

I wonder if she really needs the rock. If she deeply responds to the rock, does she need it? Maybe all she will need is to picture the rock in her mind, rub her fingers together and imagine the feeling of the stone, feel its cool temperature and recall the feelings associated with it. Maybe we'll get there. For now, I like that she has a physical thing to take with her everywhere she goes.






This guy is Marcel Proust, who wrote 7 long volumes of a novel triggered by the memories set off by a cookie: “She sent out for one of those short, plump little cakes called petites madeleines, which look as though they had been moulded in the fluted scallop of a pilgrim's shell. And soon, mechanically, weary after a dull day with the prospect of a depressing morrow, I raised to my lips a spoonful of the tea in which I had soaked a morsel of the cake. No sooner had the warm liquid, and the crumbs with it, touched my palate than a shudder ran through my whole body, and I stopped, intent upon the extraordinary changes that were taking place…at once the vicissitudes of life had become indifferent to me, its disasters innocuous, its brevity illusory…”— Remembrance of Things Past, Volume 1: Swann's Way.

The photograph at the top is from my collection and is by Edward Steichen, taken in the early 1930's at the very peak of Shirley Temple's fame. At the time, she was the most powerful star in Hollywood. How old is she in the photograph? 8? 9? Steichen captures her in a way that says she's willing and able to negotiate with any studio executive. This is a potential power in every child, and something I would look for in the photographs I acquired.

June 10, 2009

Mouse


Sometimes not knowing a diagnosis is more frightening than the diagnosis itself. Sometimes it’s frightening to suspect a serious diagnosis. It’s part of the job to share bad news if there is bad news. But what about a suspicion? Should everybody be worried or just me?

Stephen’s fifth birthday was just a month away when he was brought to me by his concerned mother. A PhD candidate at Berkeley, she had noticed some recent changes in his behavior. He was fighting more with his older sister, and was calling her bad names. Nothing in their situation had changed, she insisted. She said that the older sister did indeed tease and provoke him sometimes. They had a pretty normal sibling relationship.

But she was worried about some of the things he said in order to explain his actions. His mother had asked him why he said those mean things to his sister. She asked me to ask him in the office to see what the answer might be. I asked why he kept getting into trouble. He looked sad and said, “It’s not my fault.” I asked whose fault it was. “He made me do it,” he said. When I asked who was making him, he refused to say. I was wondering about bullies or somebody not treating this child right. I asked about the hurtful things he said. “I didn’t want to say them!” he insisted, “he tells me what to say!” This was confusing to me, and I asked the obvious question.

“The mouse tells me,” he said, looking down.

“What mouse is that?” I asked.

“The mouse that lives in my head.”

At that, the mother got up for a tissue for her tears. This made the child start to cry. Luckily, there were tissues enough for your unbiased reporter as well.

I asked him to tell me about the mouse. He said that he wasn’t sure when the mouse arrived, but there’s a mouse that lives in his brain. It tells him things to say and do, almost always to his sister. He always says the mean things, and the mouse doesn’t listen to him when he tries to explain to the mouse that he wants to say nice things.

I had a lot of questions. No, the mouse didn’t eat anything. The mouse didn’t have any friends or other animals living in his brain with him. The mouse never asked him to hurt himself or anyone else. When I asked, he said that the mouse was kind of brown. It didn’t interfere with his sleep or doing any particular activity. But he could hear it speak, and reluctantly admitted that he sometimes did what it told him to do.

Was this mental illness? I asked Stephen’s mother about all sorts of things that didn’t seem connected. Did he show a typical range of emotions for his age? Did he do anything strange, that she hadn’t seen before? Did what he say make sense? How distracted was he? Stephen, it turns out, was playful and had lots of friends. He liked playing soccer and was not moody at all. His behavior was usually completely appropriate, and he was a bright and articulate kid to talk with. Not depressed, not anxious.

Further questioning about the range of the mouse’s abilities showed it to be limited to naughty thoughts and actions having to do with his older sister. He seemed pretty well-adjusted for his age. It’s important to look for signs of dysfunction. From my point of view, I wanted to know if the mouse was interfering with his life or the tasks kids his age usually do—it wasn’t. Was the mouse there at his invitation? If it had been scary to him, if it had forced its way into his awareness and was there against his will, holding him hostage in some way, that would be concerning to me. And my global impression is important. He was a happy kid, who acted like a happy kid. He acted like a pesky younger sibling to his sister, and they sometimes fought. But even the parameters of their feuds were not out of the ordinary.

This time, I could be reassuring to Stephen’s mother, who listened to my questions with occasional alarm. This was magical thinking, which was completely normal for his age. Magical thinking is what kids do when they experience something happening, and they try to find a logical cause for it. There are so many mysteries in the lives of preschoolers, that they have many magical explanations. Maybe daddy came home late today because Stephen didn’t want to eat his vegetables. Maybe Santa brought a certain toy because he did eat his vegetables. Maybe it wasn’t his fault for calling his sister a lizard-head. In a world populated by anthropomorphic talking animals, it is perfectly rational that he could have a rodent of his own. Its home in his head gives it ready access to making him move his mouth in just the right way. About 6 months later, the mouse was gone.

June 7, 2009

The Amber Room


I like amber. It’s beautiful, has a nice not-quite-rock but not-quite-gem quality to it. It’s warm. It has dinosaur DNA.

Today I was interviewed prospectively by a mother who was looking for a new pediatrician. I always encourage parents to bring their kids with them. Kids generally like me right away, which is an advantage in my line of work. I'm not as good with adults, so having the kid there is often what sells me to the parent. She brought her 18-month-old daughter. While trying to carry on a conversation with the mother, trying to sound well-informed, I was playing peekaboo with the kid who was laughing pretty much the whole time we spoke.

I noticed that the child was wearing a short necklace of amber beads. Showing off my multicultural insight, I asked if they were Swiss or German. Mom smiled and told me they were from Germany, and the parents moved here with a job from a multinational technology firm. Mother said authoritatively that it was "to help with the teething."

She told me she was looking for a new pediatrician because every time she went to her current pediatrician, she saw a different doctor. That wasn't possible in a one-person practice like mine, of course. She liked that. I explained my belief in the benefit of a relationship between doctor and patient, even if that were a baby. I know all my patients, I will see them any time, they can call me any time. She liked that, too. She had been recommended to me.

This lovely little girl had not been vaccinated. Her mother explained that she believed that since the child was home with her all the time, she wasn't exposed to diseases and didn't need vaccination during her infancy while her immune system was still developing. She said that there was no point in putting her child at risk by vaccinating her. This mother told me that they like to travel and expect to go to central Africa in about a year. They have family in India and will visit there soon.

I have known about the amber necklace tradition since the first child of my dear Swiss friends from grad school. Has this ever been studied for teething? Does it work? How, exactly would it work? If amber is beneficial, will it work for other types of pain? What about toothaches or cavities? I didn't know any of the answers to these questions. What about the form of the amber--what if you crushed it into a powder and ate it or rubbed it onto the gums, would it work even better? Are small beads better than big beads for teething? And what about beads in general--are they safe for 16-month-olds? How about necklaces in general?

The things we do for our children are decisions. Maybe we don't have to stop and research everything, but I wonder about how all of us make medical decisions for our children.

Most parents and nurses believe that teething causes many different symptoms, including fever, pain, and drooling. Why do they think this? Does teething really cause these symptoms?

Now I am more confused than ever. There's this teething thing that's definitely real: kids go from no teeth to having teeth. That's an observable event. The first decision (1) is to decide if it's a problem. Most parents think so, but when objectively studied, a lot of the symptoms we observe look like they are caused by other things. But let's say the parent decides that teething does cause a problem. The next decision (2) is to decide if it needs to be treated. What will happen if we don't treat teething--what is the danger to the child? The parent must decide that the problem needs treatment, rather than, say, support and observation, in order to get to a decision (3) about what kind of treatment is appropriate. Pain-killing teething gel will definitely make the kid's gums numb, but it doesn't last long. Treatment decisions can be tough. What is the likely benefit of an amber necklace (4)? An amber necklace seems benign enough, but a necklace on a toddler has risks. So there's a decision (5) about risks. What if the risk is rare? That adds a decision considering how serious that rare risk might be. You might not be too concerned about the child swallowing a bead. What about choking on one? Somehow you have to decide if your measurement of benefit (4) outweighed your measurement of risk (5). That is a decision (6) too.

I wondered how she had decided about vaccinations. I didn't ask her why she had refused them. I asked her about the pieces of the final decision. How did she decide the amount of risk? How did she evaluate the benefit? What did she believe? What did she know?

Belief beats knowledge every time. How much do we have to know before it changes our beliefs?

Epilogue: After about 2 hours of friendly chat and keeping that sweet little girl amused, I was sure that this mom wasn't going to choose me as her child's doctor. I was surprised that she did, and together we made a plan to bring the child up to date on her vaccinations.


The guy in the picture on the left is Thomas Bayes, whose ideas about making decisions remain interesting to me. The picture at the top is of the Amber Room, looted from the Catherine Palace in St. Petersburg by the Germans at the end of World War II, and lost since then.

June 4, 2009

Child Behavior: Spanking


Don't hit your kids. I was actually asked about spanking this past week, and thought it was worth committing some of these concepts to whatever this medium is. The issues with spanking, of course, overlap with most other discipline issues. The question was posed to me as a philosophical one. I was asked how I feel about it. This post is only a little bit about my feelings and a lot about statistics.

A group of researchers at Phoenix Children's Hospital compiled a Report on Physical Punishment in the United States. I learned a lot.

Spanking is not a philosophical question. True enough, I don't like the idea of anybody hurting anybody. I'm not alone—29% of Americans are against physical punishment by parents and 77% think that school personnel shouldn't either. Wait, I did the math too. I was surprised to learn that 71% think it's OK for parents to hit their kids, and 23% think it's OK for somebody at school to hit their kids. Though I was surprised to learn I was in the philosophical minority about parents hitting their kids, I didn't have more than a philosophical set of objections. I found statistics.

I wondered why a school would find it necessary to physically hurt a child. Curiously, African-American students were 2.5 times more likely to get physical punishments than white students, and boys 3.4 times more likely than girls. So even if no one was consciously selecting who to hit, there was definitely some selection going on. That didn't sound fair to me.

Parents are more likely to hit their kids if:
  • They believe that it works.
  • They were hit when they were kids.
  • They are under stress.
  • They are frequently frustrated with their kids.
  • They are under 30.
  • The child is a preschooler (age 2-5).
  • They think their religion approves of it.

It's reasonable to think that the more aggressive and oppositional the child is, the more frustrating it would be to manage these behaviors. Sure enough, the active and aggressive kids get hit more. But what if it was the physical discipline that was contributing or even causing the aggressive behavior? A study was done in which new types of parenting interventions were taught to parents. Within a short time, the problem behaviors decreased. Studies of all kinds have showed that decreasing the amount of physical discipline caused a decrease in the child's problem behaviors. So it doesn't work to control the very behaviors it's aimed at—it makes them worse.

Increasing amounts of physical punishment are associated with increasing substance use problems and increasing mental health problems. These problems persist into adulthood. So you're hurting your kids for years to come.

It also won't help your children to feel close to you. Of those physically punished, children themselves, and adolescents looking back, say explicitly that they feel less warm and open toward their parents. That doesn't sound helpful.

Here's my take on this, from a parenting point of view.
  1. Spanking often was used for aggressive behavior. But the aggressive behavior of the parent actually provides unintended positive feedback that supports the child's problem behavior. It confirms the idea that hurting someone is an effective way of getting what you want from them. It's confusing at best, and counterproductive at worst.
  2. It teaches that the reason for good behavior, or not doing an unwanted behavior, is to avoid punishment. All of us are capable of being conditioned, like Pavlov's Dog. With severe enough rewards and punishments, we will find a path of least resistance. So I think it's possible that punishment will indeed get the kid to do what's desired. But they won't learn anything that could apply to a new situation. Maybe if we take away the threat, the kid won't have any reason to behave well.
  3. It's a good way to get children to be afraid of their parents. How will they model loving relationships? Is love tied to violence?

Don't hit the kids. Or anybody else's kids, either. In fact, it's probably a good idea to keep your hands to yourself.



The photo above is not from my collection. It is from Vanity Fair magazine, 1903. Under the title 'Bifurcated Girls,' it was risqué not for the scene, but for the fact that the women were wearing pants.

June 1, 2009

Buckle Up for Safety


Have you ever thought about bike helmets? No, seriously. What do they do? Do they work? Are they effective? Yes, I’m going somewhere with this.

First, the facts. Bike helmets reduce serious head injuries in people who have bike accidents. Obviously, they don’t eliminate the possibility of a serious head injury, they just reduce the likelihood of having one. Yet people wearing helmets can die in bike accidents. If you think about it, imagining reasons this could happen isn’t very difficult. The energy of a car or truck hitting a person on a bicycle is likely to overwhelm the protective power of a helmet. When I lived in Utah, I remember a case of somebody unintentionally mountain-biking off a cliff. But most bike accidents occur because the front wheel catches a rock or a curb, or gets caught in a street drain. It’s in these most common accidents that the helmet makes the most difference, potentially changing the outcome of these common accidents from uncomfortable scrapes to seriously life-altering.

So good parents will insist on their children wearing bike helmets. Better parents will make sure they fit right. Insane parents will make the kid wear the helmet to bed.

So it confuses me when I see a parent and child bicycling together (I love seeing that! Good exercise and fun with the kid!) and the child is wearing a helmet but the parent is not.

Nobody wants or anticipates an accident. That’s why they’re called accidents. Being a good, experienced, adult bicyclist does not protect you from a head injury. Wearing a helmet does. So picture the following scenarios. The child goes over the handlebars--parent stops, assesses the situation, uses the cellphone or flags down some help as needed. The parent goes over the handlebars--who is looking after the child? Can the child summon help if needed? Will the child’s judgment about what to do have suboptimal implications for the injured parent? And then how well off will the child be?

A perspective empathic to the child leads to a conclusion that the child needs a helmet, but so does the parent. So when you go bicycling with your child, please wear a helmet--for the kid’s sake.

There are, of course, other examples of this kind of decision about the safety of the child. We put our children in car seats, though they are obviously restrictive and children often don’t like them. I’ll ask the same questions as I did for bike helmets. Did you research this yourself? Do they actually work? What, specifically , do they prevent? If your child complains about sitting in one, do you give in and let them climb from back seat to front or play in the back of the station wagon like I did over 40 years ago? Why don’t you? What made you believe? After all, you know that seat belts won’t always protect you, and that plenty of people are injured and killed in auto accidents who are wearing seatbelts. Even people who never met somebody who was in a horrible car crash wear seatbelts. At some point, they believed that they are safer. I remember seeing ads on TV about buckling up for safety. My sister and I had to pester our parents about wearing seatbelts--which didn’t retract and weren’t convenient back in the stone age. It took a lot of annoying before they regularly did it just to shut us up. I wonder why they were so resistant to doing this, and I’m sad to say I have missed my chance to ask them.

I don’t think reasonable people need absolute perfection to take advantage of these potentially life-saving technologies. Most of us know that putting on that bike helmet doesn’t eliminate our risk, it just cuts it down a lot. We should act on that to help protect our children. I don’t think that most readers who got this far will think my logic particularly controversial. When it comes to sitting in the car seat or wearing a bicycle helmet, the empathic parent does not negotiate with their child. It’s helmet on or no bicycling allowed.

When I read the tragic story about the unvaccinated baby in Minnesota who died of HIB disease--pretty much preventable with vaccine since 1988--I wondered what the parents had thought beforehand. Did they do their own research or did they take somebody’s word for it? Whose word? Who did they trust to guide them about the potential protection of their child from this deadly disease? What were their information sources to make this important decision? How authoritative is a web page? Did they research the vaccine? Did they research the disease it prevents (it’s a bad one)? Did they always put the baby in a car seat?

How to fit a bike helmet video.
video