November 26, 2009

Giving Thanks

Dear father and mother, I know
I cannot your kindness repay,
But I hope as the older I grow
I may learn your commands and obey.

You loved me before I could tell
Who it was that so tenderly smiled,
And now that I know it so well,
I should be a dutiful child.

 --from a sampler by Fanny Kitson Newman, London 1832, age 6.  Yes, 6.
I like courtesy. Manners, at their core, are culturally-filtered actions that confirm the empathic nature of human interaction. OK, I'll try to put that another way. When I hold a door open for someone, and they walk through, it's nice if they say thank you. Superficially, it would be considered plain good manners. But at a deeper level, the person is acknowledging that I did something that took thought and effort, that I delayed my own journey by a little bit to make theirs a little easier. They get that I didn't have to hold the door.
Yes, it bugs me when I do this and somebody walks through the door without a glance or word, as if it were my job. And by the way, that's not enough. As if all of us haven't had our shares of thankless jobs or ungrateful bosses/ employers/ clients/ customers, getting paid does not take the place of simple, empathic, courtesy. We should thank people for a job well done.

How do we teach this kind of behavior to children?

This is a much more complicated question than parenting books would have you believe. The complication results from the understanding that each child brings to these interactions their own social programming and intuition, governed by a wide variety of influences from brain chemistry to sibling birth order. As with my perspective on parenting in general, there is no one right answer.

That being said, there are clear wrong answers. The parent who punishes the child for what is perceived as bad manners does not effectively teach the child to be polite. They may indeed condition the behavior they desire. We can indeed physically intimidate most children to get them to perform whatever tricks we have in mind for them to do. It changes a behavior without teaching any knowledge or understanding that can be applied to different situations when the threat isn't there.

For those of us who didn't go to Dartmouth in the early 1960s, an instructive documentary film provides a glimpse of a typical hazing ritual that culminates in the repetition of the phrase, "thank you sir, may I have another?" I advise all parents of college-bound children to obtain a copy and study it, in private.

Children, I believe, are a lot smarter than we often give them credit for being. They usually know--or eventually find out--when we're lying to them. It is particularly insidious to make them lie for us. That's a great way to teach them what dishonesty is and how casually we employ it.

So it continues to bother me when it unfolds in my office. One of the very least favorite things I have to do in my job is perform a painful procedure. Whether it's giving a shot or taking out a splinter, draining an infection or just finding out where it hurts, I don't look forward to it. Kids, of course, are not usually trying to repress their feelings, and are often refreshingly open about how they feel about the unpleasant activity. No good parent wants to see their child in pain and no good doctor wants to cause it. So why is it that many parents make their child say thank you as they are leaving the office?

It's fine to remind your child to say thank you after getting a lollipop. Maybe they need a little coaching to ask for one with a please. But being grateful for a shot is too much like thank you sir, may I have another.
It's true that courtesy becomes a habit and rote repetition will reinforce the habit you'd like your child to acquire. But it's the empathic foundation of manners that will actually make them into courteous people. We need to teach that. Here are some of the ways to do it.

  1. Notice them being good. It never ceases to surprise me how often children will occupy themselves quietly while a parent and I engage in important but incomprehensible conversation, and the parent doesn't notice! I really try to thank the child for helping by letting us talk about things. I tell them how great it is that they put away the blocks, or looked at the book. If there is one universal failure of parents, this is it. Like the parents of Fanny Newman, we simply expect excellent behavior. How is that different from our ungrateful boss, who simply expects our superior work product as the norm and neither notices nor rewards it? Why do parents expect their kids to do stuff without thanks? So much of what I do with behavior is managing rational expectations. You made the decision to have children and if you expected them to thank you for the privilege, your goals need to be adjusted. Seriously. If you want them to be speaking to you when you're old, you need to start right now. I have nothing against assigning them duties around the house—but if these chores get done, you still need to say thank you. Every single time. Even if it's a uniformed doorman who opens the door for you, thanking him says so much—especially if you're with your child. We need to re-train ourselves to see what's right in front of us, the child who's doing something right. And don't wait around for the kid to be doing everything right. I promise they are doing lots of things right, so don't let a day go by without thanking them for something real.

  2. Point out to them when somebody is helping them (or you). Though shopping and getting around in general can be quite an inconvenient hassle with a child, every parent's life is filled with the kindness of strangers who give up their seat on the bus, hold one of the grocery bags, or otherwise lend a hand when it's obviously needed. You might thank the person, but did you explain it to your child? Did you say it really helped us when that lady gave us her cart. That's why I said 'thank you'?

  3. Tell them how it makes you feel. Every child wants to please their parent, and they want to learn how other people do it, too. So when it's you that gets thanked for bringing over a pie, don't miss the opportunity. Tell your child that it made you feel good when you were thanked for it. You might be shocked how often your child will notice things to thank you for once you explain how this works.

  4. Don't force them to give thanks for stuff that hurts. It's not courtesy, it's counterproductive Dickensian brutality that will just teach them that these basic expressions and words are meaningless. So in #1 above, when you thank them for something, it's got to be something they know is honest. Thanking them for being 12 or for doing something you made them do (like getting shots) is not going to leave a helpful impression on an intelligent child of nearly any age.

Thanks for reading.

By the way, I found the full(?) text of the poem.  I haven't been able to find an author, so if anybody knows who wrote it, please share.

  My father, my mother, I know,
    I cannot your kindness repay;
  But I hope that, as older I grow,
    I shall learn your commands to obey.

  You loved me before I could tell
    Who it was that so tenderly smiled;
  But now that I know it so well,
    I  should be a dutiful child.

  I am sorry that ever I should
    Be naughty and give you a pain;
  I hope I shall learn to be good,
    And so never grieve you again.

  But, for fear that I should dare
    From all your commands to depart,
  Whenever I'm saying my prayer
    I'll ask for a dutiful heart.

I suppose this says a lot about the way that children were looked upon 200 years ago.  There's a lot about it that makes me uncomfortable.

November 22, 2009

Milk 2

In most of the First World, people have enough sense to appreciate the disease-prevention aspects of modern hygiene.  In most of the third world, parents sacrifice in ways we can’t imagine to get a hold of basic survival needs of their children, like clean water and pasteurized milk.

When I lived in Utah, I met people who actually believed that treatment of municipal water was, in fact, some sort of technique by which our government was trying to control its noncompliant population.  Before I moved to Utah, I thought this was a creative device sprung fully-formed from the creative genius of Stanley Kubrick and Peter George, who wrote Dr. Strangelove.  I thought I had been transported to a scene from this classic cold-war movie, in the early 1960’s.  Now that I think about it, there were a lot of things about Utah that made me feel that way.

I was asked to write a letter saying that there was a medical reason that a preschooler should not be compelled to drink raw milk.  And, in this case, raw cow colostrum.  Apparently, the raw milk just wasn’t raw enough.  Though I’ve been here in Berkeley for more than a decade, I had never heard of people drinking raw milk or giving it purposely to their children.  So I don’t know how relevant these two posts on the topic will be for normal people who live in normal places and make normal decisions.

A comment came to the previous post inquiring about the accusation that pasteurization kills the good bacteria along with the bad in milk, and doesn’t that leave us without an important source of crucial digestive flora?  I thought about how to answer this question, besides the obvious fact that very few kids drink raw milk, lots—thousands of times as many—kids drink pasteurized milk, and all those kids don’t have serious problems with their digestive ecosystems.  But I have another way to look at it.

It’s hard to study babies.  Most parents don’t want scientists messing around with their babies, and I’m not sure it’s ethical to be poking and hurting babies for the fulfillment of scientific curiosity.  But there’s one kind of study that usually flies through every committee and review board designed to protect patients from the voracious appetites of modern science.  The poop study.  Baby poop is plentiful, easily collected, doesn’t hurt the baby and is a more renewable resource than the greenest, fair-tradiest most organic product available.  When the supply in the lab runs low, it’s not that difficult to find more.  Just about everything about this miracle material that can be studied has been studied.

Meconium, the black tarry stuff that emerges shortly after the baby emerges, is sterile.  It’s what remains of the cells that have developed into the hoses and culverts of the baby’s digestive system.  Within 48 hours of birth, every gram of the fresh stuff (every 1/30th of an ounce) has about 1,000,000,000 bacteria.  Can you imagine how crowded it is down there after a year?  Yet, somehow, all of this population explosion happens without a drop of cow’s milk, raw or otherwise.  So how essential is it?

I was told that the good bacteria in raw milk act to fight off the bad bacteria, so pasteurization actually increases the risk of getting bad bacteria.  It was hard to understand this.  But it shows a serious weakness in critical thinking.  Let’s say that it works just like they say:  good bacteria keep the counts of disease-causing bacteria relatively low.  So how is this more effective than giving your kids the kind of milk with no bacteria?  How is hoping—assuming—that the dose of deadly infectious bacteria in the raw milk you’re serving won’t be high enough to kill your child better than giving your kid the kind of milk with no bacteria?  And what about the argument that if the cow is not a feedlot cow, and is raised in a relatively pristine environment, that raw milk can be the cleanest milk available?  A few such careful families decided to pool their resources and together buy a diary cow on a farm in Washington.  In 2005, after 4 cases of potentially lethal O157:H7 E. coli were found, an investigation found a total of 18 cases.  157 people were interviewed in the investigation, but nobody became ill who didn’t drink raw milk.  17 of the 18 affected people were either part of the cow-share or children of those families.  One child was a friend who had visited and was given raw milk.  Though the age range of those affected was 1-47 years old, the median age was 9.  All of the people hospitalized were 1-13 years old.  It’s not hard to figure out why.  Of those who drank 0-1 cup of milk a day, 4% got sick.  1-2 cups a day, 7% got sick.  Of those drinking 3 cups a day, 38% got sick.  Four people in this group got Hemolytic Uremic Syndrome, in which the kidneys shut down.  It’s not something you want your child to get.

In Pennsylvania in 2007, it was Salmonella Typhimurium from raw milk at a farm stand.  Sure, most people merely get extremely ill from it.  But the case-fatality rate (yes, that’s what it means) can be 5-10% in newborns or the elderly.

What if the raw milk is “certified?”  It was easy to find reports of infection from this unregulated definition.  In an outbreak in Germany, consumption of raw milk was the only food risk factor for children under 3.

And what about lactose intolerance?  Since both pasteurized and unpasteurized milk contains lactose, there’s no advantage there.  The enzyme needed to digest it, lactase, is more active in some people than others.  For the lactose-intolerant, who have low levels of lactase, drinking raw milk (which has just as much lactose as pasteurized milk) is not likely to be an improvement.

Giving young children raw milk is dangerous.  There are lots of websites with all kinds of testimonials to its benefits.  I looked for studies confirming some or any of the alleged benefits of drinking it, and found only reports of disease and death.

 The next time somebody suggests you give your child raw milk, ask them why, and then ask how they really know that it does what they claim. 

The magnificent photograph at top is by the late Harold Edgerton, a professor at MIT and inventor of the strobe light.  He discovered ways the world worked that we never had any idea about.

November 16, 2009


This week, once again, I have had the privilege of performing a duty only those of us working in the rarefied atmosphere of Berkeley California (and places like it) get to do.  I had to write a note to a preschool principal requesting—insisting, actually—that one of my patients be served only pasteurized milk.

glass of milkRemember the wax paper containers that we had in elementary school?  It was never clear which side you should open, though it did seem that one side opened easier than the other.  Often enough, for inexplicable reasons, both sides got open and the container, now missing apparently key elements of its structural architecture, would become floppy.  Drinking from it became difficult.  I’m not, just so it’s clear, nostalgic for those little containers.

To most stories, there probably are at least two sides.  The great leaders of history weren’t always the nicest people.  Certainly, along the way, history must have gotten a few of the details wrong, with the result that some of the people we admire were probably not so admirable in real life.  Here’s the thing with really big hit movies, too.  Maybe they didn’t sound so appealing when they were first released.  Maybe you weren’t so impressed when you first saw the movie.  But when not just a few but people from all over the world are seeing the movie and loving it, again and again, it must have something appealing.  So the next time you look through a list of the top 100 movies of all time, maybe you should take a chance and rent the ones you haven’t seen.  I don’t believe that the public at large is usually right about things.  But when great works of art, great people and their discoveries, stand up to the rigorous tests of time and repeated scrutiny, there’s probably a reason.

I’m willing to cut Louis Pasteur some slack.  He’s got a really famous institute named after him, and his tomb is mighty fancy.pasteur grave   That’s not enough.  In the last quarter of the 19th century, New Yorker Jacob Riis wrote about baby ‘farms’ in which some poor adults would, for money, take in babies from families who couldn’t afford to care for them.  The milk they were given wasn’t good, and these caretakers would give them opium to keep them quiet until they died.  This freed up space to take in more babies.  None of this particularly attracted attention, both  because of the poverty of the families involved and the brutal routine nature of this kind of illness.  This was chronicled in How the Other Half Lives, which Riis published in 1890.  In 1891 the infant mortality rate in New York City was 240 per 1000 births.  That’s about 1 in 4.  After a lot of controversy and debate, and after a major typhus epidemic blamed on raw milk, New York started enforcing rules about pasteurization.  Within a few years, the mortality rate for infants had dropped to 71 per 1000, 1 in 14.
The bacterium E. coli is in all of us.  It’s a normal component of our digestive system.  One subspecies of E. coli that has turned to the dark side is called O157:H7.  It’s a bad thing to get, and can make people very sick.  It can kill you.

cowsDuring a 20-year period, from 1982-2002, about 4% of all O157:H7 cases were from raw milk products and colostrum.   Think about that.  It’s hard to get raw milk in most places.  Much, much less than 4% of the population eats raw milk products.  That means that those who do have a very high risk, compared with the population as a whole, of getting this potentially deadly infection.  Do I need to say that children are particularly vulnerable?
The first time I saw a case of Hemolytic Uremic Syndrome [HUS] I was in training and working in a children’s hospital.  It’s not something you would have seen outside of an intensive care unit.  The 4-year old I watched over was on dialysis and waiting for a kidney transplant.  She got O157:H7, was sick for no more than a couple of days before her kidneys shut down.  Even with the dialysis, without her kidneys working her body found it hard to regulate important functions like blood pressure.  There was no happy ending.

I know this is a pretty dark way to come back to the blog after a week and a half or so.  But this isn’t about disease, infection, Louis Pasteur, poverty, or organic produce.  It’s about parenting.

I believe that every caring parent has the best interests of their child at heart.  But parenting requires the use of a brain, as well.

I asked the parents who requested the letter from me to ask the people at the school why, exactly, it was so important for every child to have raw milk.  They called me and said that they were told it was simply better for the child and that there were a lot of health benefits.  ‘Like what?’ they asked.  Better nutrition they were told.  ‘Really?  More vitamins or what?’  But that was as much as they could get.  This very superficial scratching of the surface of belief revealed a hollow center.

Ask me why your child shouldn’t have raw milk and I’ll tell you what I know, what I’ve seen with my own eyes, what I’ve read a dozen times from independent sources and studies all over the world—it can be lethal.  Now ask that nice person in the mom’s group why it’s worth risking your child’s life.  What precisely are the benefits that are so overwhelming to make up for that?

November 4, 2009

Swine Flu Update November 4 2009

Sometimes our government does things really right.  I think the Centers for Disease Control [CDC], year in and year out, does a great job.  And they do it for the whole world.  (At least for them, for free.)  Before any of my patients go to exotic locales, or sometimes not so exotic ones, I will check their website for up-to-the-minute news of outbreaks or cautions.  Their very best feature is a real-time Traveler's Health section, where you can find what's going on disease-wise in any place on Earth, and if your next vacation leaves you exposed to Chikungunya Fever.

Feeling this way, from years of experience, has left me particularly confused about the current H1N1 vaccine situation.  I heard from our government just months ago that there would be available 130,000,000 doses of vaccine available.  They did a fine job of publicizing the epidemic, so that many of those who never got flu vaccine before are now asking for it. 

I have a long list of children whose parents want them to get the vaccine, and many of those children have complicating risk factors.  I haven't received even 1 dose so far.  In this area, Kaiser Permanente (presumably the largest organization ordering vaccine) got theirs a couple of weeks ago.  Some other counties have had it for a while, too.  Larger medical practices are getting deliveries.  Not me, not the small practices.  When--if--I get some in my office, will it be like the seasonal flu vaccine?  I ordered it last year, received a fraction of what I ordered, and can't get more.  There is no more, and many of my patients have had to do without. 

One of the things that's so confusing is the number of doses available.  In the 3 or 4 months since the 130 million number was being mentioned to every news outlet, a large proportion of those doses failed to materialize.  I've tried to find an authoritative link on this, but haven't been able to.  A lot of sources suggest 14 million, some say a little more than that, but much will only be available in 2010.  The CDC website says that as of October 30, 2009 16,870,000 doses have been shipped.  Where did it all go?  The manufacturing cycle for vaccines is a long one.  Batches are grown, purified, prepared.  If things were going slower than expected, were they going 90% slower?  How come the government didn't know or didn't publicize that or tell us what to do instead?  Are there manufacturing plants that have broken down?  Labor unrest?  All the reasons I can think of should have been known and followed intimately by the same people and institutions that seem to have been so vigilant (and generally right, by the way) about the upcoming, now ongoing, epidemic.

I'm faced with a problem.  If I don't get enough, who do I give it to?  I know who the most vulnerable patients are, and I will be ranking them.  It's not a list you want your kid to be on top of.  But it's a list you still might want your kid to be on.  Why do I have to make this kind of choice? 

I need to point out that I am not blaming anybody for this situation.  If it were possible to deliver all the promised doses, I'm confident it would be done.  But I do feel that we all should have known long before this.  The lack of information could have serious health effects.  Next year, there will be studies of the cost of the H1N1 epidemic.  The cost of treatment, hospitalization, interventions of all kind, doctor and ER visits will be added to lost wages and time spent staying home with the sick child.  But what won't be counted is how much might have been saved--even without the vaccine--if we had been able to plan a little better with better, more timely information.

With all the above said, here's some information available this morning, as a service to my patients and their families, and to the many readers of this blog everywhere.

Questions and Answers about the H1N1 vaccine.
Is it safe?
A guide to antiviral drugs for the flu.

What to do if you or somebody close to you gets the flu.
Pregnant women and this flu.
State of California Public Health link.
City of Berkeley flu link.
FAQ for parents about H1N1

For kids, adults, and probably free:
Alameda County H1N1 vaccine clinics.
Contra Costa County H1N1 vaccine clinics.

November 1, 2009

The Transition Card

In my previous post about transitions, I introduced Max, who found it difficult to let go of one activity and take up another.  It didn’t matter if the next one was something he liked doing.  He just couldn’t break away.
Transitions can be difficult for everybody, but a behavioral problem resulting from this difficulty is developmentally most likely in preschoolers.  We tend to think of young children as having very short attention spans.  This is true for the activities we impose on them, such as sitting quietly at the dinner table while adults talk about stuff that doesn’t interest them and serve them food that interests them even less. 

The playground is a fluid environment, where the games played by children of this age morph seamlessly as we watch with rules that change moment by moment.  So in a sense, that can be taken as evidence of short attention span.  A more empathic interpretation suggests intense concentration and focused attention, unwavering over the duration of the play period. 
Postcard-for-correspondence-chess The International Correspondence Chess Federation was founded in 1951 for people serious about playing  chess, one move at a time, by mail, courier, or homing pigeon.  The picture above is an official postcard, a relatively recent innovation.  Chess is famous for requiring intense focus and concentration.  Does it require more focus than that preschool playground game of tag/rugby/steeplechase, with rules different at the end than at the beginning?  The preschool game could never be played by postcard.

I think preschoolers look at the world as an unknown territory, ripe for exploration and new discovery.  Their time in the sandbox, time with blocks is often overtly experimental.  Watch them carefully and patiently and you’ll see it too.  Maybe they want to figure out how to get a roof on the structure they made with blocks.  They try one shape of block, but that doesn’t work, then another.  Eventually they see that they have to change the support structure.  The first time a child is able to build a little tunnel or arch in sand is a triumph of inventive engineering over the inflexible physics of gravity.  This is not evidence of a short attention span.
So it’s no surprise that it can be tough to pull somebody away from an intense experiment which they feel is right on the brink of a marvelous discovery.

I suggested to Max’s mother that she give him plenty of warning.  The first, without a time frame, just to give him a head’s up that something’s coming.  Then a physical reminder such as a tap on the shoulder, at 20 minutes, 10 minutes, and 4 or 5 minutes.  Keep these reminders consistently timed, so that he eventually will get a visceral feel for how much longer he’s got. 

She loved this plan, and promised to try it right away. 

It didn’t work.  When I saw them a couple of weeks later, she told me that it did seem to help a little, because he seemed less surprised when she turned off the game/TV/light or demanded that he move to the next thing.  But he still didn’t really start to make the transition on his own, which I had honestly hoped he would do.
When children respond to this method of transition warnings, they typically complain at the first warning, try to negotiate at the 20-minute notice, but at 5 minutes they start putting away the toys that they have been playing with.  That didn’t happen with Max.

This hyperfocused state that preschoolers can be in, I suspect, is related to their concrete thinking.  Since they can’t picture themselves doing something else in the future, a future activity can’t be made more attractive to them than what they’re doing right now.  I tried to come up with a more concrete transition system for Max, that was less abstract than being told something would occur 20 minutes in the future.  From his perspective, that’s as good as never.

I took my idea from soccer.  It’s not that soccer players have a yellowcard4problem with concrete thinking (although it’s possible they do).  But soccer is so heavily international that there is no universal language with which officials can communicate with players.  They use cards.

I suggested that she work with him on making his own cards.  It’s OK that the time-warning system didn’t work.  At least he now knows that such a system exists and that it’s something you want him to do.  So explain this to him when he’s not deep into an activity, and make some cards out of cardboard.  Let him decorate or design them.  Ask him which of the cards he would like to mean 20 minutes, or 10, 5, or 2.  He can make these for you as a present that you’ll really be grateful for.  Instead of a verbal reminder, you actually hand him the appropriate card which warns of an upcoming activity change.  He may not want it, but it’s completely concrete.  Remember that part of my invention is doing it together.  When you sit together to make these cards, you should make a card for him.  It’s a 5-minute extra card, which works like the snooze button on your alarm clock.   RedCard When he gives it to you, he gets another 5 minutes.  You have to honor this!  Here’s a subtle point in my invention:  he gives you the 5-minute extra card.  That means he doesn’t get another and another and another.  It becomes way more difficult to whine and negotiate when you have given away all the currency of time which these cards represent.   You can show some concrete thinking, too.