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Playing the ‘Doctor’ Card: A Lesson in Three Hypotheticals
Scenario I. Let’s say you wake with a collection of symptoms. None of them is concerning, but the combination seems a bit unusual, or at least confusing. You would like to speak to your PCP, whom you have known for a long time, and ask for either reassurance or advice on whether you should make an appointment. However, your experience with the front office’s organization tells you that the quick 4-minute conversation you’re looking for is not going to happen easily.
You have that robotic phone message memorized. It begins suggesting that you think you have an emergency to call 911. Then it reminds you that if have a question about COVID to press “2,” which will take you to a recorded message and eventually link you to a triage nurse if the recording doesn’t answer your questions. If you need a prescription refill you should press “3.” If you are a doctor’s office and wish speak to the doctor press “4.” If you know you need an appointment press “5.” And finally if you have a question press “6” and leave a message and a nurse will get back to you before the end of the day.
The good news is that your PCP’s office is good to its word and will return your call the same day, but the bad news is that it is likely to be well into the afternoon. And, while you don’t consider your symptoms life-threatening, you don’t want getting an answer to be an exercise in schedule disruption.
You were a doctor before you retired and you still have an “office.” It’s really more of a combination den and studio. So, technically you are a doctor’s office wanting to speak to the doctor. And, you know that pressing “4” will get you the answer you are looking for in a matter of minutes.
Scenario II. Your spouse, or your aunt, or the elderly widow next door asks you to accompany her at an upcoming doctor’s visit because she had been having trouble understanding the physician’s plan regarding further diagnosis and possible treatment. She believes having you along as kind of an interpreter/advocate would be a big help. Do you agree and do you make any stipulations?
Scenario III. Your PCP has referred you to a specialist. You are filling out the previsit form(s). Do you list your occupation as “retired physician” or just “retired”? Or just leave it blank?
Whether you deserve it or not, graduating from medical school has conferred on you a specialness in the eyes of many people. It is assumed you are smarter than the average bear and in taking the Hippocratic oath you have joined an elite club. And, with that membership comes some special undefined privileges.
But with that specialness there are are some downsides. For example, in some states being a physician once allowed you to have a license plate with “MD” in the number sequence. Sometimes that helped you avoid the occasional parking ticket. That is until folks realized the “MD” made you a target for car thieves and drug seekers who mistakenly believe we all carry drugs in our glove compartments.
So what about that first scenario? Do you press “4” to jump yourself to the head of the queue and avoid the inconvenience of having to wait for a reasonably timely response from your PCP? After all, you are fellow physicians and you’ve known her for a decade or two. If you are retired is your time any more valuable than that of her other patients? If you are still in active practice you can argue that getting special attention will benefit your patients. But, if it’s a weekend and you are off it’s a bit harder to rationalize special treatment. Playing the doctor card in this situation is your own decision but you must be prepared to shoulder the perceptions by your PCP and her staff as well as your own sense of fairness.
The other two scenarios are much different. In neither are you risking the impression that you are asking for a favor. But, they each have their downsides. In the second scenario you are doing someone a favor to act as an interpreter. How could this have downside? Unfortunately, what happens too often in situations like this is that when the patient’s physician learns that you are a fellow physician, the rest of the visit becomes a dialogue in doctor-speak between the two physicians with the patient sitting by as an observer. In the end this discussion may benefit the patient by creating a treatment plan that the patient can understand either because they overheard it or more likely because you eventually explained it to them.
On the other the hand, this doctor-to-doctor chat has done nothing to build a doctor-patient relationship that had obviously been lacking something. In situations like this it is probably better to keep the doctor card up your sleeve to be played at the end of the visit or maybe not at all. Before agreeing to be an interpreter/advocate, ask the patient to avoid mentioning that you are a physician. Instead, ask that she introduce you as a friend or relative that she has asked to come along to serve as a memory bank. During the visit it may be helpful to occasionally interject and suggest that the patient ask a question that hasn’t been adequately addressed. While some physicians may be upset when they belatedly find you have not revealed up front that you are a physician, I find this a harmless omission that has the benefit of improving patient care.
The final scenario — in which you are the patient — is likely to occur more often as you get older. When filling out a previsit form, I often simply put retired or leave it blank. But, how I answer the question often seems to be irrelevant because I have learned that physicians and their staff read those boilerplate forms so cursorily that even when I report my status as “retired physician” everyone seems surprised if and when it later comes to light.
My rationale in keeping the doctor card close to my vest in these situations is that I want to be addressed without any assumptions regarding my medical knowledge, which in my situation is well over half a century old and spotty at best. I don’t want my physicians to say “I’m sure you understand.” Because I often don’t. I would like them to learn about who I am just as I hope they would other patients. I won’t be offended if they “talk down” to me. If this specialist is as good as I’ve heard she is, I want to hear her full performance, not one edited for fellow and former physicians.
It doesn’t arrive gold edged with a list of special privileges. If it comes with any extras, they are risks that must be avoided.
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 pdnews@mdedge.com.
Scenario I. Let’s say you wake with a collection of symptoms. None of them is concerning, but the combination seems a bit unusual, or at least confusing. You would like to speak to your PCP, whom you have known for a long time, and ask for either reassurance or advice on whether you should make an appointment. However, your experience with the front office’s organization tells you that the quick 4-minute conversation you’re looking for is not going to happen easily.
You have that robotic phone message memorized. It begins suggesting that you think you have an emergency to call 911. Then it reminds you that if have a question about COVID to press “2,” which will take you to a recorded message and eventually link you to a triage nurse if the recording doesn’t answer your questions. If you need a prescription refill you should press “3.” If you are a doctor’s office and wish speak to the doctor press “4.” If you know you need an appointment press “5.” And finally if you have a question press “6” and leave a message and a nurse will get back to you before the end of the day.
The good news is that your PCP’s office is good to its word and will return your call the same day, but the bad news is that it is likely to be well into the afternoon. And, while you don’t consider your symptoms life-threatening, you don’t want getting an answer to be an exercise in schedule disruption.
You were a doctor before you retired and you still have an “office.” It’s really more of a combination den and studio. So, technically you are a doctor’s office wanting to speak to the doctor. And, you know that pressing “4” will get you the answer you are looking for in a matter of minutes.
Scenario II. Your spouse, or your aunt, or the elderly widow next door asks you to accompany her at an upcoming doctor’s visit because she had been having trouble understanding the physician’s plan regarding further diagnosis and possible treatment. She believes having you along as kind of an interpreter/advocate would be a big help. Do you agree and do you make any stipulations?
Scenario III. Your PCP has referred you to a specialist. You are filling out the previsit form(s). Do you list your occupation as “retired physician” or just “retired”? Or just leave it blank?
Whether you deserve it or not, graduating from medical school has conferred on you a specialness in the eyes of many people. It is assumed you are smarter than the average bear and in taking the Hippocratic oath you have joined an elite club. And, with that membership comes some special undefined privileges.
But with that specialness there are are some downsides. For example, in some states being a physician once allowed you to have a license plate with “MD” in the number sequence. Sometimes that helped you avoid the occasional parking ticket. That is until folks realized the “MD” made you a target for car thieves and drug seekers who mistakenly believe we all carry drugs in our glove compartments.
So what about that first scenario? Do you press “4” to jump yourself to the head of the queue and avoid the inconvenience of having to wait for a reasonably timely response from your PCP? After all, you are fellow physicians and you’ve known her for a decade or two. If you are retired is your time any more valuable than that of her other patients? If you are still in active practice you can argue that getting special attention will benefit your patients. But, if it’s a weekend and you are off it’s a bit harder to rationalize special treatment. Playing the doctor card in this situation is your own decision but you must be prepared to shoulder the perceptions by your PCP and her staff as well as your own sense of fairness.
The other two scenarios are much different. In neither are you risking the impression that you are asking for a favor. But, they each have their downsides. In the second scenario you are doing someone a favor to act as an interpreter. How could this have downside? Unfortunately, what happens too often in situations like this is that when the patient’s physician learns that you are a fellow physician, the rest of the visit becomes a dialogue in doctor-speak between the two physicians with the patient sitting by as an observer. In the end this discussion may benefit the patient by creating a treatment plan that the patient can understand either because they overheard it or more likely because you eventually explained it to them.
On the other the hand, this doctor-to-doctor chat has done nothing to build a doctor-patient relationship that had obviously been lacking something. In situations like this it is probably better to keep the doctor card up your sleeve to be played at the end of the visit or maybe not at all. Before agreeing to be an interpreter/advocate, ask the patient to avoid mentioning that you are a physician. Instead, ask that she introduce you as a friend or relative that she has asked to come along to serve as a memory bank. During the visit it may be helpful to occasionally interject and suggest that the patient ask a question that hasn’t been adequately addressed. While some physicians may be upset when they belatedly find you have not revealed up front that you are a physician, I find this a harmless omission that has the benefit of improving patient care.
The final scenario — in which you are the patient — is likely to occur more often as you get older. When filling out a previsit form, I often simply put retired or leave it blank. But, how I answer the question often seems to be irrelevant because I have learned that physicians and their staff read those boilerplate forms so cursorily that even when I report my status as “retired physician” everyone seems surprised if and when it later comes to light.
My rationale in keeping the doctor card close to my vest in these situations is that I want to be addressed without any assumptions regarding my medical knowledge, which in my situation is well over half a century old and spotty at best. I don’t want my physicians to say “I’m sure you understand.” Because I often don’t. I would like them to learn about who I am just as I hope they would other patients. I won’t be offended if they “talk down” to me. If this specialist is as good as I’ve heard she is, I want to hear her full performance, not one edited for fellow and former physicians.
It doesn’t arrive gold edged with a list of special privileges. If it comes with any extras, they are risks that must be avoided.
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 pdnews@mdedge.com.
Scenario I. Let’s say you wake with a collection of symptoms. None of them is concerning, but the combination seems a bit unusual, or at least confusing. You would like to speak to your PCP, whom you have known for a long time, and ask for either reassurance or advice on whether you should make an appointment. However, your experience with the front office’s organization tells you that the quick 4-minute conversation you’re looking for is not going to happen easily.
You have that robotic phone message memorized. It begins suggesting that you think you have an emergency to call 911. Then it reminds you that if have a question about COVID to press “2,” which will take you to a recorded message and eventually link you to a triage nurse if the recording doesn’t answer your questions. If you need a prescription refill you should press “3.” If you are a doctor’s office and wish speak to the doctor press “4.” If you know you need an appointment press “5.” And finally if you have a question press “6” and leave a message and a nurse will get back to you before the end of the day.
The good news is that your PCP’s office is good to its word and will return your call the same day, but the bad news is that it is likely to be well into the afternoon. And, while you don’t consider your symptoms life-threatening, you don’t want getting an answer to be an exercise in schedule disruption.
You were a doctor before you retired and you still have an “office.” It’s really more of a combination den and studio. So, technically you are a doctor’s office wanting to speak to the doctor. And, you know that pressing “4” will get you the answer you are looking for in a matter of minutes.
Scenario II. Your spouse, or your aunt, or the elderly widow next door asks you to accompany her at an upcoming doctor’s visit because she had been having trouble understanding the physician’s plan regarding further diagnosis and possible treatment. She believes having you along as kind of an interpreter/advocate would be a big help. Do you agree and do you make any stipulations?
Scenario III. Your PCP has referred you to a specialist. You are filling out the previsit form(s). Do you list your occupation as “retired physician” or just “retired”? Or just leave it blank?
Whether you deserve it or not, graduating from medical school has conferred on you a specialness in the eyes of many people. It is assumed you are smarter than the average bear and in taking the Hippocratic oath you have joined an elite club. And, with that membership comes some special undefined privileges.
But with that specialness there are are some downsides. For example, in some states being a physician once allowed you to have a license plate with “MD” in the number sequence. Sometimes that helped you avoid the occasional parking ticket. That is until folks realized the “MD” made you a target for car thieves and drug seekers who mistakenly believe we all carry drugs in our glove compartments.
So what about that first scenario? Do you press “4” to jump yourself to the head of the queue and avoid the inconvenience of having to wait for a reasonably timely response from your PCP? After all, you are fellow physicians and you’ve known her for a decade or two. If you are retired is your time any more valuable than that of her other patients? If you are still in active practice you can argue that getting special attention will benefit your patients. But, if it’s a weekend and you are off it’s a bit harder to rationalize special treatment. Playing the doctor card in this situation is your own decision but you must be prepared to shoulder the perceptions by your PCP and her staff as well as your own sense of fairness.
The other two scenarios are much different. In neither are you risking the impression that you are asking for a favor. But, they each have their downsides. In the second scenario you are doing someone a favor to act as an interpreter. How could this have downside? Unfortunately, what happens too often in situations like this is that when the patient’s physician learns that you are a fellow physician, the rest of the visit becomes a dialogue in doctor-speak between the two physicians with the patient sitting by as an observer. In the end this discussion may benefit the patient by creating a treatment plan that the patient can understand either because they overheard it or more likely because you eventually explained it to them.
On the other the hand, this doctor-to-doctor chat has done nothing to build a doctor-patient relationship that had obviously been lacking something. In situations like this it is probably better to keep the doctor card up your sleeve to be played at the end of the visit or maybe not at all. Before agreeing to be an interpreter/advocate, ask the patient to avoid mentioning that you are a physician. Instead, ask that she introduce you as a friend or relative that she has asked to come along to serve as a memory bank. During the visit it may be helpful to occasionally interject and suggest that the patient ask a question that hasn’t been adequately addressed. While some physicians may be upset when they belatedly find you have not revealed up front that you are a physician, I find this a harmless omission that has the benefit of improving patient care.
The final scenario — in which you are the patient — is likely to occur more often as you get older. When filling out a previsit form, I often simply put retired or leave it blank. But, how I answer the question often seems to be irrelevant because I have learned that physicians and their staff read those boilerplate forms so cursorily that even when I report my status as “retired physician” everyone seems surprised if and when it later comes to light.
My rationale in keeping the doctor card close to my vest in these situations is that I want to be addressed without any assumptions regarding my medical knowledge, which in my situation is well over half a century old and spotty at best. I don’t want my physicians to say “I’m sure you understand.” Because I often don’t. I would like them to learn about who I am just as I hope they would other patients. I won’t be offended if they “talk down” to me. If this specialist is as good as I’ve heard she is, I want to hear her full performance, not one edited for fellow and former physicians.
It doesn’t arrive gold edged with a list of special privileges. If it comes with any extras, they are risks that must be avoided.
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 pdnews@mdedge.com.
Baby-Led Weaning
I first heard the term “baby-led weaning” about 20 years ago, which turns out was just a few years after the concept was introduced to the public by a public health/midwife in Britain. Starting infants on solid foods when they could feed themselves didn’t sound as off-the-wall to me as it did to most other folks, but I chose not to include it in my list of standard recommendations at the 4- and 6-month well child visits. If any parent had asked me my opinion I would have told them to give it a try with a few specific cautions about what and how. But, I don’t recall any parents asking me. The ones who knew me well or had read, or at least heard about, my book on picky eating must have already figured out what my answer would be. The parents who didn’t know me may have been afraid I would tell them it was a crazy idea.
Twelve years ago I retired from office practice and hadn’t heard a peep about baby-led weaning until last week when I encountered a story in The New York Times. It appears that while I have been reveling in my post-practice existence, baby-led weaning has become a “thing.” As the author of the article observed: “The concept seems to appeal to millennials who favor parenting philosophies that prioritize child autonomy.”
Baby-led weaning’s traction has been so robust that the largest manufacturer of baby food in this country has been labeling some of its products “baby-led friendly since 2021.” There are several online businesses that have tapped into the growing market. One offers a very detailed free directory that lists almost any edible you can imagine with recommendations of when and how they can be presented in a safe and appealing matter to little hand feeders. Of course the company has also figured out a way to monetize the product.
Not surprisingly the American Academy of Pediatrics (AAP) has remained silent on baby-led weaning. However, in The New York Times article, Dr. Mark R. Corkins, chair of the AAP nutrition committee, is quoted as describing baby-led weaning is “a social media–driven invention.”
While I was interested to learn about the concept’s growth and commercialization, I was troubled to find that like co-sleeping, sleep training, and exclusive breastfeeding, baby-led weaning has become one of those angst-producing topics that is torturing new parents who live every day in fear that they “aren’t doing it right.” We pediatricians might deserve a small dose of blame for not vigorously emphasizing that there are numerous ways to skin that cat known as parenting. However, social media websites and Mom chat rooms are probably more responsible for creating an atmosphere in which parents are afraid of being ostracized for the decisions they have made in good faith whether it is about weaning or when to start toilet training.
In isolated cultures, weaning a baby to solids was probably never a topic for discussion or debate. New parents did what their parents did, or more likely a child’s grandmother advised or took over the process herself. The child was fed what the rest of the family ate. If it was something the infant could handle himself you gave it to him. If not you mashed it up or maybe you chewed it for him into a consistency he could manage.
However, most new parents have become so distanced from their own parents’ childrearing practices geographically, temporally, and philosophically, that they must rely on folks like us and others whom they believe are, or at least claim to be, experts. Young adults are no longer hesitant to cross ethnic thresholds when they decide to be co-parents, meaning that any remnant of family tradition is either diluted or lost outright. In the void created by this abandonment of tradition, corporations were happy to step in with easy-to-prepare baby food that lacks in nutritional and dietary variety. Baby-led weaning is just one more logical step in the metamorphosis of our society’s infant feeding patterns.
I still have no problem with baby-led weaning as an option for parents, particularly if with just a click of a mouse they can access safe and healthy advice to make up for generations of grandmotherly experience acquired over hundreds of years. However,
It is one thing when parents hoping to encourage the process of self-feeding offer their infants an edible that may not be in the family’s usual diet. However, it is a totally different matter when a family allows itself to become dietary contortionists to a accommodate a 4-year-old whose diet consists of a monotonous rotation of three pasta shapes topped with grated Parmesan cheese, and on a good day a raw carrot slice or two. Parents living in this nutritional wasteland may have given up on managing their children’s pickiness, and may find it is less stressful to join the child and eat a few forkfuls of pasta to preserve some semblance of a family dinner. Then after the child has been put to bed they have their own balanced meal.
Almost by definition family meals are a compromise. Even adults without children negotiate often unspoken menu patterns with their partners. “This evening we’ll have your favorite, I may have my favorite next week.”
Most parents of young children understand that their diet may be a bit heavier on pasta than they might prefer and a little less varied when it comes to vegetables. It is just part of the deal. However, when mealtimes become totally dictated by the pickiness of a child there is a problem. While a poorly structured child-led family diet may be nutritionally deficient, the bigger problem is that it is expensive in time and labor, two resources usually in short supply in young families.
Theoretically, infants who have led their own weaning are more likely to have been introduced to a broad variety of flavors and textures and this may carry them into childhood as more adventuresome eaters. Picky eating can be managed successfully and result in a family that can enjoy the psychological and emotional benefits of nutritionally balanced family meals, but it requires a combination of parental courage and patience.
It is unclear exactly how we got into a situation in which a generation of parents makes things more difficult for themselves by favoring practices that overemphasize child autonomy. It may be that the parents had suffered under autocratic parents themselves, or more likely they have read too many novels or watched too many movies and TV shows in which the parents were portrayed as overbearing or controlling. Or, it may simply be that they haven’t had enough exposure to young children to realize that they all benefit from clear limits to a varying degree.
In the process of watching tens of thousands of parents, it has become clear to me that those who are the most successful are leaders and that they lead primarily by example. They have learned to be masters in the art of deception by creating a safe environment with sensible limits while at the same time fostering an atmosphere in which the child sees himself as participating in the process.
The biblical prophet Isaiah (11:6-9) in his description of how things will be different after the Lord acts to help his people predicts: “and a little child shall lead them.” This prediction fits nicely as the last in a string of crazy situations that includes a wolf living with a lamb and a leopard lying down with a calf.
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 pdnews@mdedge.com.
I first heard the term “baby-led weaning” about 20 years ago, which turns out was just a few years after the concept was introduced to the public by a public health/midwife in Britain. Starting infants on solid foods when they could feed themselves didn’t sound as off-the-wall to me as it did to most other folks, but I chose not to include it in my list of standard recommendations at the 4- and 6-month well child visits. If any parent had asked me my opinion I would have told them to give it a try with a few specific cautions about what and how. But, I don’t recall any parents asking me. The ones who knew me well or had read, or at least heard about, my book on picky eating must have already figured out what my answer would be. The parents who didn’t know me may have been afraid I would tell them it was a crazy idea.
Twelve years ago I retired from office practice and hadn’t heard a peep about baby-led weaning until last week when I encountered a story in The New York Times. It appears that while I have been reveling in my post-practice existence, baby-led weaning has become a “thing.” As the author of the article observed: “The concept seems to appeal to millennials who favor parenting philosophies that prioritize child autonomy.”
Baby-led weaning’s traction has been so robust that the largest manufacturer of baby food in this country has been labeling some of its products “baby-led friendly since 2021.” There are several online businesses that have tapped into the growing market. One offers a very detailed free directory that lists almost any edible you can imagine with recommendations of when and how they can be presented in a safe and appealing matter to little hand feeders. Of course the company has also figured out a way to monetize the product.
Not surprisingly the American Academy of Pediatrics (AAP) has remained silent on baby-led weaning. However, in The New York Times article, Dr. Mark R. Corkins, chair of the AAP nutrition committee, is quoted as describing baby-led weaning is “a social media–driven invention.”
While I was interested to learn about the concept’s growth and commercialization, I was troubled to find that like co-sleeping, sleep training, and exclusive breastfeeding, baby-led weaning has become one of those angst-producing topics that is torturing new parents who live every day in fear that they “aren’t doing it right.” We pediatricians might deserve a small dose of blame for not vigorously emphasizing that there are numerous ways to skin that cat known as parenting. However, social media websites and Mom chat rooms are probably more responsible for creating an atmosphere in which parents are afraid of being ostracized for the decisions they have made in good faith whether it is about weaning or when to start toilet training.
In isolated cultures, weaning a baby to solids was probably never a topic for discussion or debate. New parents did what their parents did, or more likely a child’s grandmother advised or took over the process herself. The child was fed what the rest of the family ate. If it was something the infant could handle himself you gave it to him. If not you mashed it up or maybe you chewed it for him into a consistency he could manage.
However, most new parents have become so distanced from their own parents’ childrearing practices geographically, temporally, and philosophically, that they must rely on folks like us and others whom they believe are, or at least claim to be, experts. Young adults are no longer hesitant to cross ethnic thresholds when they decide to be co-parents, meaning that any remnant of family tradition is either diluted or lost outright. In the void created by this abandonment of tradition, corporations were happy to step in with easy-to-prepare baby food that lacks in nutritional and dietary variety. Baby-led weaning is just one more logical step in the metamorphosis of our society’s infant feeding patterns.
I still have no problem with baby-led weaning as an option for parents, particularly if with just a click of a mouse they can access safe and healthy advice to make up for generations of grandmotherly experience acquired over hundreds of years. However,
It is one thing when parents hoping to encourage the process of self-feeding offer their infants an edible that may not be in the family’s usual diet. However, it is a totally different matter when a family allows itself to become dietary contortionists to a accommodate a 4-year-old whose diet consists of a monotonous rotation of three pasta shapes topped with grated Parmesan cheese, and on a good day a raw carrot slice or two. Parents living in this nutritional wasteland may have given up on managing their children’s pickiness, and may find it is less stressful to join the child and eat a few forkfuls of pasta to preserve some semblance of a family dinner. Then after the child has been put to bed they have their own balanced meal.
Almost by definition family meals are a compromise. Even adults without children negotiate often unspoken menu patterns with their partners. “This evening we’ll have your favorite, I may have my favorite next week.”
Most parents of young children understand that their diet may be a bit heavier on pasta than they might prefer and a little less varied when it comes to vegetables. It is just part of the deal. However, when mealtimes become totally dictated by the pickiness of a child there is a problem. While a poorly structured child-led family diet may be nutritionally deficient, the bigger problem is that it is expensive in time and labor, two resources usually in short supply in young families.
Theoretically, infants who have led their own weaning are more likely to have been introduced to a broad variety of flavors and textures and this may carry them into childhood as more adventuresome eaters. Picky eating can be managed successfully and result in a family that can enjoy the psychological and emotional benefits of nutritionally balanced family meals, but it requires a combination of parental courage and patience.
It is unclear exactly how we got into a situation in which a generation of parents makes things more difficult for themselves by favoring practices that overemphasize child autonomy. It may be that the parents had suffered under autocratic parents themselves, or more likely they have read too many novels or watched too many movies and TV shows in which the parents were portrayed as overbearing or controlling. Or, it may simply be that they haven’t had enough exposure to young children to realize that they all benefit from clear limits to a varying degree.
In the process of watching tens of thousands of parents, it has become clear to me that those who are the most successful are leaders and that they lead primarily by example. They have learned to be masters in the art of deception by creating a safe environment with sensible limits while at the same time fostering an atmosphere in which the child sees himself as participating in the process.
The biblical prophet Isaiah (11:6-9) in his description of how things will be different after the Lord acts to help his people predicts: “and a little child shall lead them.” This prediction fits nicely as the last in a string of crazy situations that includes a wolf living with a lamb and a leopard lying down with a calf.
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 pdnews@mdedge.com.
I first heard the term “baby-led weaning” about 20 years ago, which turns out was just a few years after the concept was introduced to the public by a public health/midwife in Britain. Starting infants on solid foods when they could feed themselves didn’t sound as off-the-wall to me as it did to most other folks, but I chose not to include it in my list of standard recommendations at the 4- and 6-month well child visits. If any parent had asked me my opinion I would have told them to give it a try with a few specific cautions about what and how. But, I don’t recall any parents asking me. The ones who knew me well or had read, or at least heard about, my book on picky eating must have already figured out what my answer would be. The parents who didn’t know me may have been afraid I would tell them it was a crazy idea.
Twelve years ago I retired from office practice and hadn’t heard a peep about baby-led weaning until last week when I encountered a story in The New York Times. It appears that while I have been reveling in my post-practice existence, baby-led weaning has become a “thing.” As the author of the article observed: “The concept seems to appeal to millennials who favor parenting philosophies that prioritize child autonomy.”
Baby-led weaning’s traction has been so robust that the largest manufacturer of baby food in this country has been labeling some of its products “baby-led friendly since 2021.” There are several online businesses that have tapped into the growing market. One offers a very detailed free directory that lists almost any edible you can imagine with recommendations of when and how they can be presented in a safe and appealing matter to little hand feeders. Of course the company has also figured out a way to monetize the product.
Not surprisingly the American Academy of Pediatrics (AAP) has remained silent on baby-led weaning. However, in The New York Times article, Dr. Mark R. Corkins, chair of the AAP nutrition committee, is quoted as describing baby-led weaning is “a social media–driven invention.”
While I was interested to learn about the concept’s growth and commercialization, I was troubled to find that like co-sleeping, sleep training, and exclusive breastfeeding, baby-led weaning has become one of those angst-producing topics that is torturing new parents who live every day in fear that they “aren’t doing it right.” We pediatricians might deserve a small dose of blame for not vigorously emphasizing that there are numerous ways to skin that cat known as parenting. However, social media websites and Mom chat rooms are probably more responsible for creating an atmosphere in which parents are afraid of being ostracized for the decisions they have made in good faith whether it is about weaning or when to start toilet training.
In isolated cultures, weaning a baby to solids was probably never a topic for discussion or debate. New parents did what their parents did, or more likely a child’s grandmother advised or took over the process herself. The child was fed what the rest of the family ate. If it was something the infant could handle himself you gave it to him. If not you mashed it up or maybe you chewed it for him into a consistency he could manage.
However, most new parents have become so distanced from their own parents’ childrearing practices geographically, temporally, and philosophically, that they must rely on folks like us and others whom they believe are, or at least claim to be, experts. Young adults are no longer hesitant to cross ethnic thresholds when they decide to be co-parents, meaning that any remnant of family tradition is either diluted or lost outright. In the void created by this abandonment of tradition, corporations were happy to step in with easy-to-prepare baby food that lacks in nutritional and dietary variety. Baby-led weaning is just one more logical step in the metamorphosis of our society’s infant feeding patterns.
I still have no problem with baby-led weaning as an option for parents, particularly if with just a click of a mouse they can access safe and healthy advice to make up for generations of grandmotherly experience acquired over hundreds of years. However,
It is one thing when parents hoping to encourage the process of self-feeding offer their infants an edible that may not be in the family’s usual diet. However, it is a totally different matter when a family allows itself to become dietary contortionists to a accommodate a 4-year-old whose diet consists of a monotonous rotation of three pasta shapes topped with grated Parmesan cheese, and on a good day a raw carrot slice or two. Parents living in this nutritional wasteland may have given up on managing their children’s pickiness, and may find it is less stressful to join the child and eat a few forkfuls of pasta to preserve some semblance of a family dinner. Then after the child has been put to bed they have their own balanced meal.
Almost by definition family meals are a compromise. Even adults without children negotiate often unspoken menu patterns with their partners. “This evening we’ll have your favorite, I may have my favorite next week.”
Most parents of young children understand that their diet may be a bit heavier on pasta than they might prefer and a little less varied when it comes to vegetables. It is just part of the deal. However, when mealtimes become totally dictated by the pickiness of a child there is a problem. While a poorly structured child-led family diet may be nutritionally deficient, the bigger problem is that it is expensive in time and labor, two resources usually in short supply in young families.
Theoretically, infants who have led their own weaning are more likely to have been introduced to a broad variety of flavors and textures and this may carry them into childhood as more adventuresome eaters. Picky eating can be managed successfully and result in a family that can enjoy the psychological and emotional benefits of nutritionally balanced family meals, but it requires a combination of parental courage and patience.
It is unclear exactly how we got into a situation in which a generation of parents makes things more difficult for themselves by favoring practices that overemphasize child autonomy. It may be that the parents had suffered under autocratic parents themselves, or more likely they have read too many novels or watched too many movies and TV shows in which the parents were portrayed as overbearing or controlling. Or, it may simply be that they haven’t had enough exposure to young children to realize that they all benefit from clear limits to a varying degree.
In the process of watching tens of thousands of parents, it has become clear to me that those who are the most successful are leaders and that they lead primarily by example. They have learned to be masters in the art of deception by creating a safe environment with sensible limits while at the same time fostering an atmosphere in which the child sees himself as participating in the process.
The biblical prophet Isaiah (11:6-9) in his description of how things will be different after the Lord acts to help his people predicts: “and a little child shall lead them.” This prediction fits nicely as the last in a string of crazy situations that includes a wolf living with a lamb and a leopard lying down with a calf.
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 pdnews@mdedge.com.
Long COVID and Blame Hunting
I suspect that many of you have seen or read about a recent study regarding the “long COVID” enigma. The investigators surveyed the records of more than 4000 pediatric patients who had been infected and nearly 1400 who had not. The researchers then developed models in which 14 symptoms were more common in previous SARS-CoV2–infected individuals in all age groups, compared with the uninfected. There were four additional symptoms in children only and three additional symptoms in the adolescents.
Using these data, the investigators created research indices that “correlated with poor overall health and quality of life” and emphasized “neurocognitive, pain, and gastrointestinal symptoms in school-age children” and a “change or loss in smell or taste, pain, and fatigue/malaise-related symptoms in adolescents.”
So now thanks to these investigators we have research indices for characterizing PASC (post-acute sequelae of SARS-CoV-2, aka. long COVID). What should we to do with them? I’m not sure these results move us any further if our goal is finding something to help patients who believe, or have been told, that they have long COVID.
Even to a non-statistician like myself there appear to be some problems with this study. In an editorial accompanying this study, Suchitra Rao, MBBS, MSCS in the Department of Pediatrics, University of Colorado School of Medicine, Aurora, noted the study has the potential for ascertainment bias. For example, the researchers’ subject recruitment procedure resulted in a higher “proportion of neurocognitive/behavioral manifestations” may have skewed the results.
Also, some of the patient evaluations were not done at a consistent interval after the initial infection, which could result in recall bias. And, more importantly, because there were no baseline measurements to determine preinfection status, the investigators had no way of determining to what degree the patients’ underlying conditions may have reflected the quality of life scores.
Although I wouldn’t consider it a bias, I wonder if the investigators have a preconceived vision of what long COVID is going to look like once it is better understood. The fact that they undertook this project suggests that they believe the truth about the phenomenon will be discoverable using data based on collections of vague symptoms.
Or, do the researchers share my vision of long COVID that if it exists it will be something akin to the burst of Parkinson’s disease seen decades later in survivors of the 1918-1920 flu pandemic. Or, maybe it is something like post-polio syndrome, in which survivors in childhood develop atrophy and muscle weakness as they age. Do the researchers believe that COVID survivors are harboring some remnant of SARS-CoV-2 or its genome inside their bodies ticking like a time bomb ready to surface in the future? Think shingles.
I suspect that there are some folks who may or not share my ticking time bomb vision, but who, like me, wonder if there is really such a thing as long COVID – at least one in the form characterized by the work of these investigators. Unfortunately, the $1 billion the National Institutes of Health has invested in the Researching COVID to Enhance Recovery (RECOVER) initiative is not going to discover delayed sequelae until time is ready to tell us. What researchers are looking at now is a collection of patients, some who were not well to begin with but now describe a collection of vague symptoms, some of which are unique to COVID, but most are not. The loss of taste and smell being the one notable and important exception.
It is easy to understand why patients and their physicians would like to have a diagnosis like “long COVID” to at least validate their symptoms that up until now have eluded explanation or remedy. Not surprisingly, they may feel that, if researchers can’t find a cure, let’s at least have something we can lay the blame on.
A major flaw in this current attempt to characterize long COVID is the lack of a true control group. Yes, the subjects the researchers labeled as “uninfected” lived contemporaneously with the patients unfortunate enough to have acquired the virus. However, this illness was mysterious from its first appearance, continued to be more frightening as we struggled to learn more about it, and was clumsily managed in a way that turned our way of life upside down. This was particularly true for school-age children. It unmasked previously unsuspected underlying conditions and quickly acquired a poorly documented reputation for having a “long” variety.
Of course the “uninfected” also lived through these same tumultuous times. But knowing that you harbored, and may still harbor, this mysterious invader moves the infected and their families into a whole new level of concern and anxiety the rest of us who were more fortunate don’t share.
We must not ignore the fact that patients and their caregivers may receive some comfort when they have something to blame for their symptoms. However, we must shift our focus away from blame hunting, which up to this point has been fruitless. Instead, Each patient should be treated as an individual and not part of a group with similar symptoms cobbled together with data acquired under a cloud of bias.
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 pdnews@mdedge.com.
I suspect that many of you have seen or read about a recent study regarding the “long COVID” enigma. The investigators surveyed the records of more than 4000 pediatric patients who had been infected and nearly 1400 who had not. The researchers then developed models in which 14 symptoms were more common in previous SARS-CoV2–infected individuals in all age groups, compared with the uninfected. There were four additional symptoms in children only and three additional symptoms in the adolescents.
Using these data, the investigators created research indices that “correlated with poor overall health and quality of life” and emphasized “neurocognitive, pain, and gastrointestinal symptoms in school-age children” and a “change or loss in smell or taste, pain, and fatigue/malaise-related symptoms in adolescents.”
So now thanks to these investigators we have research indices for characterizing PASC (post-acute sequelae of SARS-CoV-2, aka. long COVID). What should we to do with them? I’m not sure these results move us any further if our goal is finding something to help patients who believe, or have been told, that they have long COVID.
Even to a non-statistician like myself there appear to be some problems with this study. In an editorial accompanying this study, Suchitra Rao, MBBS, MSCS in the Department of Pediatrics, University of Colorado School of Medicine, Aurora, noted the study has the potential for ascertainment bias. For example, the researchers’ subject recruitment procedure resulted in a higher “proportion of neurocognitive/behavioral manifestations” may have skewed the results.
Also, some of the patient evaluations were not done at a consistent interval after the initial infection, which could result in recall bias. And, more importantly, because there were no baseline measurements to determine preinfection status, the investigators had no way of determining to what degree the patients’ underlying conditions may have reflected the quality of life scores.
Although I wouldn’t consider it a bias, I wonder if the investigators have a preconceived vision of what long COVID is going to look like once it is better understood. The fact that they undertook this project suggests that they believe the truth about the phenomenon will be discoverable using data based on collections of vague symptoms.
Or, do the researchers share my vision of long COVID that if it exists it will be something akin to the burst of Parkinson’s disease seen decades later in survivors of the 1918-1920 flu pandemic. Or, maybe it is something like post-polio syndrome, in which survivors in childhood develop atrophy and muscle weakness as they age. Do the researchers believe that COVID survivors are harboring some remnant of SARS-CoV-2 or its genome inside their bodies ticking like a time bomb ready to surface in the future? Think shingles.
I suspect that there are some folks who may or not share my ticking time bomb vision, but who, like me, wonder if there is really such a thing as long COVID – at least one in the form characterized by the work of these investigators. Unfortunately, the $1 billion the National Institutes of Health has invested in the Researching COVID to Enhance Recovery (RECOVER) initiative is not going to discover delayed sequelae until time is ready to tell us. What researchers are looking at now is a collection of patients, some who were not well to begin with but now describe a collection of vague symptoms, some of which are unique to COVID, but most are not. The loss of taste and smell being the one notable and important exception.
It is easy to understand why patients and their physicians would like to have a diagnosis like “long COVID” to at least validate their symptoms that up until now have eluded explanation or remedy. Not surprisingly, they may feel that, if researchers can’t find a cure, let’s at least have something we can lay the blame on.
A major flaw in this current attempt to characterize long COVID is the lack of a true control group. Yes, the subjects the researchers labeled as “uninfected” lived contemporaneously with the patients unfortunate enough to have acquired the virus. However, this illness was mysterious from its first appearance, continued to be more frightening as we struggled to learn more about it, and was clumsily managed in a way that turned our way of life upside down. This was particularly true for school-age children. It unmasked previously unsuspected underlying conditions and quickly acquired a poorly documented reputation for having a “long” variety.
Of course the “uninfected” also lived through these same tumultuous times. But knowing that you harbored, and may still harbor, this mysterious invader moves the infected and their families into a whole new level of concern and anxiety the rest of us who were more fortunate don’t share.
We must not ignore the fact that patients and their caregivers may receive some comfort when they have something to blame for their symptoms. However, we must shift our focus away from blame hunting, which up to this point has been fruitless. Instead, Each patient should be treated as an individual and not part of a group with similar symptoms cobbled together with data acquired under a cloud of bias.
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 pdnews@mdedge.com.
I suspect that many of you have seen or read about a recent study regarding the “long COVID” enigma. The investigators surveyed the records of more than 4000 pediatric patients who had been infected and nearly 1400 who had not. The researchers then developed models in which 14 symptoms were more common in previous SARS-CoV2–infected individuals in all age groups, compared with the uninfected. There were four additional symptoms in children only and three additional symptoms in the adolescents.
Using these data, the investigators created research indices that “correlated with poor overall health and quality of life” and emphasized “neurocognitive, pain, and gastrointestinal symptoms in school-age children” and a “change or loss in smell or taste, pain, and fatigue/malaise-related symptoms in adolescents.”
So now thanks to these investigators we have research indices for characterizing PASC (post-acute sequelae of SARS-CoV-2, aka. long COVID). What should we to do with them? I’m not sure these results move us any further if our goal is finding something to help patients who believe, or have been told, that they have long COVID.
Even to a non-statistician like myself there appear to be some problems with this study. In an editorial accompanying this study, Suchitra Rao, MBBS, MSCS in the Department of Pediatrics, University of Colorado School of Medicine, Aurora, noted the study has the potential for ascertainment bias. For example, the researchers’ subject recruitment procedure resulted in a higher “proportion of neurocognitive/behavioral manifestations” may have skewed the results.
Also, some of the patient evaluations were not done at a consistent interval after the initial infection, which could result in recall bias. And, more importantly, because there were no baseline measurements to determine preinfection status, the investigators had no way of determining to what degree the patients’ underlying conditions may have reflected the quality of life scores.
Although I wouldn’t consider it a bias, I wonder if the investigators have a preconceived vision of what long COVID is going to look like once it is better understood. The fact that they undertook this project suggests that they believe the truth about the phenomenon will be discoverable using data based on collections of vague symptoms.
Or, do the researchers share my vision of long COVID that if it exists it will be something akin to the burst of Parkinson’s disease seen decades later in survivors of the 1918-1920 flu pandemic. Or, maybe it is something like post-polio syndrome, in which survivors in childhood develop atrophy and muscle weakness as they age. Do the researchers believe that COVID survivors are harboring some remnant of SARS-CoV-2 or its genome inside their bodies ticking like a time bomb ready to surface in the future? Think shingles.
I suspect that there are some folks who may or not share my ticking time bomb vision, but who, like me, wonder if there is really such a thing as long COVID – at least one in the form characterized by the work of these investigators. Unfortunately, the $1 billion the National Institutes of Health has invested in the Researching COVID to Enhance Recovery (RECOVER) initiative is not going to discover delayed sequelae until time is ready to tell us. What researchers are looking at now is a collection of patients, some who were not well to begin with but now describe a collection of vague symptoms, some of which are unique to COVID, but most are not. The loss of taste and smell being the one notable and important exception.
It is easy to understand why patients and their physicians would like to have a diagnosis like “long COVID” to at least validate their symptoms that up until now have eluded explanation or remedy. Not surprisingly, they may feel that, if researchers can’t find a cure, let’s at least have something we can lay the blame on.
A major flaw in this current attempt to characterize long COVID is the lack of a true control group. Yes, the subjects the researchers labeled as “uninfected” lived contemporaneously with the patients unfortunate enough to have acquired the virus. However, this illness was mysterious from its first appearance, continued to be more frightening as we struggled to learn more about it, and was clumsily managed in a way that turned our way of life upside down. This was particularly true for school-age children. It unmasked previously unsuspected underlying conditions and quickly acquired a poorly documented reputation for having a “long” variety.
Of course the “uninfected” also lived through these same tumultuous times. But knowing that you harbored, and may still harbor, this mysterious invader moves the infected and their families into a whole new level of concern and anxiety the rest of us who were more fortunate don’t share.
We must not ignore the fact that patients and their caregivers may receive some comfort when they have something to blame for their symptoms. However, we must shift our focus away from blame hunting, which up to this point has been fruitless. Instead, Each patient should be treated as an individual and not part of a group with similar symptoms cobbled together with data acquired under a cloud of bias.
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 pdnews@mdedge.com.
Being An Outsider
Our son works for a Maine-based company that produces and sells clothing and outdoor recreation equipment. One of its tag lines is “Be an Outsider.” In his role as chief marketing officer, he was recently given an app for his phone that can calculate how many minutes he spends outside each day. He assured me: “Dad, you don’t need one of these on your phone. Your weather-beaten skin says you are already logging in way more than enough minutes outdoors.”
But, it got me thinking about several avenues of research where an app like that would be useful. As luck would have it, the following week I stumbled across a paper describing just such a study.
Researchers in Shanghai, China, placed smartwatches with technology similar to my son’s phone on nearly 3000 children and found “that outdoor exposure patterns characterized by a continuous period of at least 15 minutes, accompanied by a sunlight intensity of more than 2000 lux, were associated with less myopic shift.” In other words, children getting more time outside were less likely to become nearsighted.” Whether this was an effect of being outside instead of staring at a screen indoors is an interesting question.
I have alway suspected that being outdoors was important for wellness and this paper meshed nicely with an article I had recently read in The Washington Post titled, “How time in nature builds happier, healthier and more social children” (Jamie Friedlander Serrano, 2024 Aug 4). The reporter quotes numerous experts in child health and includes links to several articles that tout the benefits of outdoor experiences, particularly ones in a natural environment. There are the vitamin D effects on growth and bone health. There are studies suggesting that being out in nature can reduce stress, anxiety, and aggression, and improve working memory and attention.
In this country there is a small but growing group of schools modeling themselves after the “Forest kindergartens” that have become popular in Europe in which a large portion of the students’ days are spent outside surrounded by nature. It will be interesting to see how robustly this trend grows here in the United States. However, in a nation like ours in which the Environmental Protection Agency estimates that the average American spends 90% of his day indoors, it’s going to require a seismic shift in our societal norms.
I think my mother always knew that being outdoors was healthy for children. I also suspect that she and most my friends’ mothers were primarily motivated by a desire to have the house to themselves. This was primarily to allow them to get the housework done unimpeded by pestering children. But, there may have been times when a busy housewife simply needed to sit down with a book in the peace and quiet of a childless environment. We kids were told to get out of the house and return for lunch and dinner, hopefully not in the tow of a police officer. There were few rules and for the most part we were left to invent our own amusement.
Yes, you’ve heard this old-fogey legend before. But it was true. Those were the halcyon days of the 1950s in a small suburban town of 5000 of a little more than 1 square mile with its own swimming pool. My particular idyll was aptly named Pleasantville but I know we were not alone as the only community where children were allowed – or let’s say “encouraged” – to be outdoors if they weren’t in school. It was a different time.
I am not so naive to believe that we will ever return to those good old days when children roamed free, but it is worth considering what has changed to drive children inside and away from all the health benefits of being outdoors. Is there anything we can do to reverse this unfortunate trend?
First, we must first face up to the reality that our society has become so focused on the potential downsides of everything that we seem to be driven primarily by risk avoidance. We hear how things can go terribly wrong in the world outside, a world we can’t control. Although the data from the pandemic don’t support it, more of us believe children are safer indoors. Parents in particular seem to worry more now than they did 75 years ago. I don’t think we can point to a single event such as the tragedies of September 11 to explain the shift.
While bad news has always traveled fast, today (with communication being almost instantaneous) a story about a child abduction at 6 in the morning in Nevada can be on my local TV channel by lunchtime here in Maine. Parents worry that if bad stuff can happen to a child in Mount Elsewhere, it could happen to my child playing in the backyard across the street.
I think we pediatricians should consider how large a role we may be playing in driving parental anxiety with our frequent warnings about the dangers a child can encounter outdoors whether they come in the form of accidents or exposure to the elements.
While parents have grown more hesitant to send their children outside to play, as a society we have failed to adequately acknowledge and respond to the role that unhealthy attraction of indoor alternatives to outdoor play may be contributing to indoorism. Here we’re talking about television, smartphones, and the internet.
So, what can we do as pediatricians to get our patients outside? First, we can set an example and cover our office walls with pictures of ourselves and our families enjoying the outdoors. We can be vocal advocates for creating and maintaining accessible outdoor spaces in our community. We can advocate for more outside time during recess in school and encourage the school officials to consider having more courses taught outside.
We can be more diligent in asking families about their screen use and not be afraid to express our concern when we hear how little outdoor time their child is getting. Finally, we can strive for more balance in our messaging. For example for every warning we give about playing outside on poor air quality days there should be a reminder of the health benefits of being outdoors on the other days. Every message about the importance of sunscreen should be preceded by a few sentences promoting outdoor activities in wooded environments where sun exposure is less of a concern.
Being an outsider is just as important as getting enough sleep, eating the right food and staying physically active.
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 pdnews@mdedge.com.
Our son works for a Maine-based company that produces and sells clothing and outdoor recreation equipment. One of its tag lines is “Be an Outsider.” In his role as chief marketing officer, he was recently given an app for his phone that can calculate how many minutes he spends outside each day. He assured me: “Dad, you don’t need one of these on your phone. Your weather-beaten skin says you are already logging in way more than enough minutes outdoors.”
But, it got me thinking about several avenues of research where an app like that would be useful. As luck would have it, the following week I stumbled across a paper describing just such a study.
Researchers in Shanghai, China, placed smartwatches with technology similar to my son’s phone on nearly 3000 children and found “that outdoor exposure patterns characterized by a continuous period of at least 15 minutes, accompanied by a sunlight intensity of more than 2000 lux, were associated with less myopic shift.” In other words, children getting more time outside were less likely to become nearsighted.” Whether this was an effect of being outside instead of staring at a screen indoors is an interesting question.
I have alway suspected that being outdoors was important for wellness and this paper meshed nicely with an article I had recently read in The Washington Post titled, “How time in nature builds happier, healthier and more social children” (Jamie Friedlander Serrano, 2024 Aug 4). The reporter quotes numerous experts in child health and includes links to several articles that tout the benefits of outdoor experiences, particularly ones in a natural environment. There are the vitamin D effects on growth and bone health. There are studies suggesting that being out in nature can reduce stress, anxiety, and aggression, and improve working memory and attention.
In this country there is a small but growing group of schools modeling themselves after the “Forest kindergartens” that have become popular in Europe in which a large portion of the students’ days are spent outside surrounded by nature. It will be interesting to see how robustly this trend grows here in the United States. However, in a nation like ours in which the Environmental Protection Agency estimates that the average American spends 90% of his day indoors, it’s going to require a seismic shift in our societal norms.
I think my mother always knew that being outdoors was healthy for children. I also suspect that she and most my friends’ mothers were primarily motivated by a desire to have the house to themselves. This was primarily to allow them to get the housework done unimpeded by pestering children. But, there may have been times when a busy housewife simply needed to sit down with a book in the peace and quiet of a childless environment. We kids were told to get out of the house and return for lunch and dinner, hopefully not in the tow of a police officer. There were few rules and for the most part we were left to invent our own amusement.
Yes, you’ve heard this old-fogey legend before. But it was true. Those were the halcyon days of the 1950s in a small suburban town of 5000 of a little more than 1 square mile with its own swimming pool. My particular idyll was aptly named Pleasantville but I know we were not alone as the only community where children were allowed – or let’s say “encouraged” – to be outdoors if they weren’t in school. It was a different time.
I am not so naive to believe that we will ever return to those good old days when children roamed free, but it is worth considering what has changed to drive children inside and away from all the health benefits of being outdoors. Is there anything we can do to reverse this unfortunate trend?
First, we must first face up to the reality that our society has become so focused on the potential downsides of everything that we seem to be driven primarily by risk avoidance. We hear how things can go terribly wrong in the world outside, a world we can’t control. Although the data from the pandemic don’t support it, more of us believe children are safer indoors. Parents in particular seem to worry more now than they did 75 years ago. I don’t think we can point to a single event such as the tragedies of September 11 to explain the shift.
While bad news has always traveled fast, today (with communication being almost instantaneous) a story about a child abduction at 6 in the morning in Nevada can be on my local TV channel by lunchtime here in Maine. Parents worry that if bad stuff can happen to a child in Mount Elsewhere, it could happen to my child playing in the backyard across the street.
I think we pediatricians should consider how large a role we may be playing in driving parental anxiety with our frequent warnings about the dangers a child can encounter outdoors whether they come in the form of accidents or exposure to the elements.
While parents have grown more hesitant to send their children outside to play, as a society we have failed to adequately acknowledge and respond to the role that unhealthy attraction of indoor alternatives to outdoor play may be contributing to indoorism. Here we’re talking about television, smartphones, and the internet.
So, what can we do as pediatricians to get our patients outside? First, we can set an example and cover our office walls with pictures of ourselves and our families enjoying the outdoors. We can be vocal advocates for creating and maintaining accessible outdoor spaces in our community. We can advocate for more outside time during recess in school and encourage the school officials to consider having more courses taught outside.
We can be more diligent in asking families about their screen use and not be afraid to express our concern when we hear how little outdoor time their child is getting. Finally, we can strive for more balance in our messaging. For example for every warning we give about playing outside on poor air quality days there should be a reminder of the health benefits of being outdoors on the other days. Every message about the importance of sunscreen should be preceded by a few sentences promoting outdoor activities in wooded environments where sun exposure is less of a concern.
Being an outsider is just as important as getting enough sleep, eating the right food and staying physically active.
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 pdnews@mdedge.com.
Our son works for a Maine-based company that produces and sells clothing and outdoor recreation equipment. One of its tag lines is “Be an Outsider.” In his role as chief marketing officer, he was recently given an app for his phone that can calculate how many minutes he spends outside each day. He assured me: “Dad, you don’t need one of these on your phone. Your weather-beaten skin says you are already logging in way more than enough minutes outdoors.”
But, it got me thinking about several avenues of research where an app like that would be useful. As luck would have it, the following week I stumbled across a paper describing just such a study.
Researchers in Shanghai, China, placed smartwatches with technology similar to my son’s phone on nearly 3000 children and found “that outdoor exposure patterns characterized by a continuous period of at least 15 minutes, accompanied by a sunlight intensity of more than 2000 lux, were associated with less myopic shift.” In other words, children getting more time outside were less likely to become nearsighted.” Whether this was an effect of being outside instead of staring at a screen indoors is an interesting question.
I have alway suspected that being outdoors was important for wellness and this paper meshed nicely with an article I had recently read in The Washington Post titled, “How time in nature builds happier, healthier and more social children” (Jamie Friedlander Serrano, 2024 Aug 4). The reporter quotes numerous experts in child health and includes links to several articles that tout the benefits of outdoor experiences, particularly ones in a natural environment. There are the vitamin D effects on growth and bone health. There are studies suggesting that being out in nature can reduce stress, anxiety, and aggression, and improve working memory and attention.
In this country there is a small but growing group of schools modeling themselves after the “Forest kindergartens” that have become popular in Europe in which a large portion of the students’ days are spent outside surrounded by nature. It will be interesting to see how robustly this trend grows here in the United States. However, in a nation like ours in which the Environmental Protection Agency estimates that the average American spends 90% of his day indoors, it’s going to require a seismic shift in our societal norms.
I think my mother always knew that being outdoors was healthy for children. I also suspect that she and most my friends’ mothers were primarily motivated by a desire to have the house to themselves. This was primarily to allow them to get the housework done unimpeded by pestering children. But, there may have been times when a busy housewife simply needed to sit down with a book in the peace and quiet of a childless environment. We kids were told to get out of the house and return for lunch and dinner, hopefully not in the tow of a police officer. There were few rules and for the most part we were left to invent our own amusement.
Yes, you’ve heard this old-fogey legend before. But it was true. Those were the halcyon days of the 1950s in a small suburban town of 5000 of a little more than 1 square mile with its own swimming pool. My particular idyll was aptly named Pleasantville but I know we were not alone as the only community where children were allowed – or let’s say “encouraged” – to be outdoors if they weren’t in school. It was a different time.
I am not so naive to believe that we will ever return to those good old days when children roamed free, but it is worth considering what has changed to drive children inside and away from all the health benefits of being outdoors. Is there anything we can do to reverse this unfortunate trend?
First, we must first face up to the reality that our society has become so focused on the potential downsides of everything that we seem to be driven primarily by risk avoidance. We hear how things can go terribly wrong in the world outside, a world we can’t control. Although the data from the pandemic don’t support it, more of us believe children are safer indoors. Parents in particular seem to worry more now than they did 75 years ago. I don’t think we can point to a single event such as the tragedies of September 11 to explain the shift.
While bad news has always traveled fast, today (with communication being almost instantaneous) a story about a child abduction at 6 in the morning in Nevada can be on my local TV channel by lunchtime here in Maine. Parents worry that if bad stuff can happen to a child in Mount Elsewhere, it could happen to my child playing in the backyard across the street.
I think we pediatricians should consider how large a role we may be playing in driving parental anxiety with our frequent warnings about the dangers a child can encounter outdoors whether they come in the form of accidents or exposure to the elements.
While parents have grown more hesitant to send their children outside to play, as a society we have failed to adequately acknowledge and respond to the role that unhealthy attraction of indoor alternatives to outdoor play may be contributing to indoorism. Here we’re talking about television, smartphones, and the internet.
So, what can we do as pediatricians to get our patients outside? First, we can set an example and cover our office walls with pictures of ourselves and our families enjoying the outdoors. We can be vocal advocates for creating and maintaining accessible outdoor spaces in our community. We can advocate for more outside time during recess in school and encourage the school officials to consider having more courses taught outside.
We can be more diligent in asking families about their screen use and not be afraid to express our concern when we hear how little outdoor time their child is getting. Finally, we can strive for more balance in our messaging. For example for every warning we give about playing outside on poor air quality days there should be a reminder of the health benefits of being outdoors on the other days. Every message about the importance of sunscreen should be preceded by a few sentences promoting outdoor activities in wooded environments where sun exposure is less of a concern.
Being an outsider is just as important as getting enough sleep, eating the right food and staying physically active.
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 pdnews@mdedge.com.
Technoference
You see it all the time. It’s the family at the table next to you in the restaurant where the two teenage children are texting away on their phones. Or the playground, where a 3-year-old is playing with his toy truck and bulldozer in the sand and his father, immersed in his laptop, hasn’t said a word to his child.
It may trouble you when you witness social situations like that in which an electronic device is preventing or certainly interfering with interpersonal interactions. Or at least I hope it troubles you. Maybe it is so ubiquitous that you have come to accept it as the norm. It’s likely you may even be a participant. But, do you have a name for it?
It’s called “technoference,” a word coined by a doctoral student in human development and family studies at Penn State a decade ago “to describe the everyday intrusions and interruptions in couple interactions that take place due to technology devices and their always-on, ever-present nature.” Although, the original research that triggered the coinage was about couples, obviously the phenomenon occurs whenever people of any age are together in social situations.
While the word may not have crept into common parlance, we all know it when we see it. Technoference may not appear in the paper’s title, but it is a subject being investigated across a broad array of disciplines. One phone tracking study found that parents of young infants spend more than 5 hours each day on their smartphones. More than a quarter of that time the infant is engaged with the parent’s digital device. Technoference has been associated with decreased parent-child interaction during early childhood. It has been associated with more negative responses to children’s behavior, as well as an increased risk of child injury.
There are numerous studies suggesting an association between parental technoference and mental health difficulties in children. I have recently reviewed one of these studies that looks at the relationship of perceived parental technoference and the mental health of children entering adolescents. The authors collected longitudinal data of more than 1300 emerging adolescents, hoping to determine if the relationship between parental distraction and mental health was bidirectional. In other words, could a child’s mental health be contributing to his parents’ perceived distraction? Or was it primarily the parents’ technoference that was playing a role in the child’s mental health problems?
What investigators found was that higher levels of parental distraction were associated with higher levels of inattention and hyperactivity in the emerging adolescents, but not vice versa. On the other hand, higher levels of adolescent anxiety was associated with higher levels of perceived parental technoference, but not vice versa.
I know this sounds a bit confusing and a bit chicken-egg-chicken-eggish. The study was not designed to determine causation in these associations. However, the authors offer some possible scenarios that may provide a bit of clarity. It could be that parents who are concerned about their anxious child respond by retreating into the cyberspace to avoid tense situations or for support or information.
On the other hand, This explanation meshes with other studies demonstrating an association between parental distraction and aggression and attention problems in early childhood.
While one could spend more time imagining other factors that could be driving these bidirectional relationships, I’m not sure that it makes a heckuva lot of difference. Whether the child’s mental illness is the primary driver or the parent’s device-associated distraction is the dominant force isn’t the point. These are bidirectional relationships. If we are interested in pointing fingers, the common denominator is the device and our failure as a society to keep it in proper perspective. We all know that smartphones, tablets, and computers create an unhealthy distraction in personal relationships. The parents know and most of the children know. It’s time for us all to demonstrate some self-discipline. And that can begin for us as health care providers as we sit behind our computers spending more time looking at the screen than we do engaging the patient with our eyes.
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 pdnews@mdedge.com.
You see it all the time. It’s the family at the table next to you in the restaurant where the two teenage children are texting away on their phones. Or the playground, where a 3-year-old is playing with his toy truck and bulldozer in the sand and his father, immersed in his laptop, hasn’t said a word to his child.
It may trouble you when you witness social situations like that in which an electronic device is preventing or certainly interfering with interpersonal interactions. Or at least I hope it troubles you. Maybe it is so ubiquitous that you have come to accept it as the norm. It’s likely you may even be a participant. But, do you have a name for it?
It’s called “technoference,” a word coined by a doctoral student in human development and family studies at Penn State a decade ago “to describe the everyday intrusions and interruptions in couple interactions that take place due to technology devices and their always-on, ever-present nature.” Although, the original research that triggered the coinage was about couples, obviously the phenomenon occurs whenever people of any age are together in social situations.
While the word may not have crept into common parlance, we all know it when we see it. Technoference may not appear in the paper’s title, but it is a subject being investigated across a broad array of disciplines. One phone tracking study found that parents of young infants spend more than 5 hours each day on their smartphones. More than a quarter of that time the infant is engaged with the parent’s digital device. Technoference has been associated with decreased parent-child interaction during early childhood. It has been associated with more negative responses to children’s behavior, as well as an increased risk of child injury.
There are numerous studies suggesting an association between parental technoference and mental health difficulties in children. I have recently reviewed one of these studies that looks at the relationship of perceived parental technoference and the mental health of children entering adolescents. The authors collected longitudinal data of more than 1300 emerging adolescents, hoping to determine if the relationship between parental distraction and mental health was bidirectional. In other words, could a child’s mental health be contributing to his parents’ perceived distraction? Or was it primarily the parents’ technoference that was playing a role in the child’s mental health problems?
What investigators found was that higher levels of parental distraction were associated with higher levels of inattention and hyperactivity in the emerging adolescents, but not vice versa. On the other hand, higher levels of adolescent anxiety was associated with higher levels of perceived parental technoference, but not vice versa.
I know this sounds a bit confusing and a bit chicken-egg-chicken-eggish. The study was not designed to determine causation in these associations. However, the authors offer some possible scenarios that may provide a bit of clarity. It could be that parents who are concerned about their anxious child respond by retreating into the cyberspace to avoid tense situations or for support or information.
On the other hand, This explanation meshes with other studies demonstrating an association between parental distraction and aggression and attention problems in early childhood.
While one could spend more time imagining other factors that could be driving these bidirectional relationships, I’m not sure that it makes a heckuva lot of difference. Whether the child’s mental illness is the primary driver or the parent’s device-associated distraction is the dominant force isn’t the point. These are bidirectional relationships. If we are interested in pointing fingers, the common denominator is the device and our failure as a society to keep it in proper perspective. We all know that smartphones, tablets, and computers create an unhealthy distraction in personal relationships. The parents know and most of the children know. It’s time for us all to demonstrate some self-discipline. And that can begin for us as health care providers as we sit behind our computers spending more time looking at the screen than we do engaging the patient with our eyes.
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 pdnews@mdedge.com.
You see it all the time. It’s the family at the table next to you in the restaurant where the two teenage children are texting away on their phones. Or the playground, where a 3-year-old is playing with his toy truck and bulldozer in the sand and his father, immersed in his laptop, hasn’t said a word to his child.
It may trouble you when you witness social situations like that in which an electronic device is preventing or certainly interfering with interpersonal interactions. Or at least I hope it troubles you. Maybe it is so ubiquitous that you have come to accept it as the norm. It’s likely you may even be a participant. But, do you have a name for it?
It’s called “technoference,” a word coined by a doctoral student in human development and family studies at Penn State a decade ago “to describe the everyday intrusions and interruptions in couple interactions that take place due to technology devices and their always-on, ever-present nature.” Although, the original research that triggered the coinage was about couples, obviously the phenomenon occurs whenever people of any age are together in social situations.
While the word may not have crept into common parlance, we all know it when we see it. Technoference may not appear in the paper’s title, but it is a subject being investigated across a broad array of disciplines. One phone tracking study found that parents of young infants spend more than 5 hours each day on their smartphones. More than a quarter of that time the infant is engaged with the parent’s digital device. Technoference has been associated with decreased parent-child interaction during early childhood. It has been associated with more negative responses to children’s behavior, as well as an increased risk of child injury.
There are numerous studies suggesting an association between parental technoference and mental health difficulties in children. I have recently reviewed one of these studies that looks at the relationship of perceived parental technoference and the mental health of children entering adolescents. The authors collected longitudinal data of more than 1300 emerging adolescents, hoping to determine if the relationship between parental distraction and mental health was bidirectional. In other words, could a child’s mental health be contributing to his parents’ perceived distraction? Or was it primarily the parents’ technoference that was playing a role in the child’s mental health problems?
What investigators found was that higher levels of parental distraction were associated with higher levels of inattention and hyperactivity in the emerging adolescents, but not vice versa. On the other hand, higher levels of adolescent anxiety was associated with higher levels of perceived parental technoference, but not vice versa.
I know this sounds a bit confusing and a bit chicken-egg-chicken-eggish. The study was not designed to determine causation in these associations. However, the authors offer some possible scenarios that may provide a bit of clarity. It could be that parents who are concerned about their anxious child respond by retreating into the cyberspace to avoid tense situations or for support or information.
On the other hand, This explanation meshes with other studies demonstrating an association between parental distraction and aggression and attention problems in early childhood.
While one could spend more time imagining other factors that could be driving these bidirectional relationships, I’m not sure that it makes a heckuva lot of difference. Whether the child’s mental illness is the primary driver or the parent’s device-associated distraction is the dominant force isn’t the point. These are bidirectional relationships. If we are interested in pointing fingers, the common denominator is the device and our failure as a society to keep it in proper perspective. We all know that smartphones, tablets, and computers create an unhealthy distraction in personal relationships. The parents know and most of the children know. It’s time for us all to demonstrate some self-discipline. And that can begin for us as health care providers as we sit behind our computers spending more time looking at the screen than we do engaging the patient with our eyes.
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 pdnews@mdedge.com.
E-Bikes: The Good ... and the Ugly
Bicycles have been woven into my life since I first straddled a hand-me-down with a fan belt drive when I was 3. At age 12 my friend Ricky and I took a 250 mile–plus 2-night adventure on our 3-speed “English” style bikes. We still marvel that our parents let us do it when neither cell phones nor GPS existed.
I have always bike commuted to work, including the years when that involved a perilous navigation into Boston from the suburbs. In our mid-50s my wife and I biked from Washington state back here to Maine with another couple unsupported. We continue to do at least one self-guided cycle tour out of the country each year.
Not surprisingly, I keep a close eye on what’s happening in the bicycle market. For decades the trends have shifted back and forth between sleek road models and beefier off-roaders. There have been boom years here and there for the dealers and manufacturers, but nothing like what the bike industry is experiencing now with the arrival of e-bikes on the market. Driven primarily by electrification, micromobility ridership (which includes conventional bikes and scooters) has grown more than 50-fold over the last 10 years. Projections suggest the market’s value will be $300 billion by 2030.
It doesn’t take an MBA with a major in marketing to understand the broad appeal of electrification. Most adults have ridden a bicycle as children, but several decades of gap years has left many of them with a level of fitness that makes pedaling against the wind or up any incline difficult and unappealing. An e-bike can put even the least fitness conscious back in the saddle and open the options for outdoor recreation they haven’t dreamed of since childhood.
In large part the people flocking to e-bikes are retiree’s who thought they were “over the hill.” They are having so much fun they don’t care if the Lycra-clad “serious” cyclists notice the battery bulge in the frame on their e-bikes. Another group of e-bike adopters are motivated by the “greenness” of a fossil-fuel–free electric powered transportation which, with minimal compromise, can be used as they would a car around town and for longer commutes than they would have considered on a purely pedal-powered bicycle.
Unfortunately, there is a growing group of younger e-bike riders who are motivated and uninhibited by the potential that the power boost of a small electric motor can provide. And here is where the ugliness begins to intrude on what was otherwise a beautiful and expanding landscape. However, it is the young who are, not surprisingly, drawn to the speed, and with any vehicle – motorized or conventional – as speed increases so does the frequency and seriousness of accidents.
The term e-bike covers a broad range of vehicles, from those designated class 1, which require pedaling and are limited to 20 miles per hour, to class 3, which may have a throttle and unmodified can hit 28 mph. Class 2 bikes have a throttle that will allow the rider to reach 20 mph without pedaling. Modifying any class of e-bike can substantially increase its speed, but this is more common in classes 2 and 3. As an example, some very fast micromobiles are considered unclassified e-bikes and avoid being labeled motorcycles simply because they have pedals.
One has to give some credit to the e-bike industry for eventually adopting this classification system. But, we must give the rest of us, including parents and public safety officials, a failing grade for doing a poor job of translating these scores into enforceable regulations to protect both riders and pedestrians from serious injury.
On the governmental side only a little more than half of US states have used the three category classification to craft their regulations. Many jurisdictions have failed to differentiate between streets, sidewalks, and trails. Regulations vary from state to state, and many states leave it up to local communities. From my experience chairing our town’s Bicycle and Pedestrian Advisory Committee, I can tell you that even “progressive” communities are struggling to decide who can ride what where. The result has been that people of all ages, but mostly adolescents, are traveling on busy streets and sidewalks at speeds that put themselves and pedestrians at risk.
On the parental side of the problem are families that have either allowed or enabled their children to ride class 2 and 3 e-bikes without proper safety equipment or consideration for the safety of the rest of the community. Currently, this is not much of a problem here in Maine thanks to the weather and the high price of e-bikes. However, I frequently visit an affluent community in the San Francisco Bay Area, where it is not uncommon to see middle school children speeding along well in excess of 20 mph.
Unfortunately this is another example, like television and cell phone, in which our society has been unable to keep up with technology by molding the behavior of our children and/or creating enforceable rules that allow us to reap the benefits of new discoveries while minimizing the collateral damage that can accompany them.
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 pdnews@mdedge.com.
Bicycles have been woven into my life since I first straddled a hand-me-down with a fan belt drive when I was 3. At age 12 my friend Ricky and I took a 250 mile–plus 2-night adventure on our 3-speed “English” style bikes. We still marvel that our parents let us do it when neither cell phones nor GPS existed.
I have always bike commuted to work, including the years when that involved a perilous navigation into Boston from the suburbs. In our mid-50s my wife and I biked from Washington state back here to Maine with another couple unsupported. We continue to do at least one self-guided cycle tour out of the country each year.
Not surprisingly, I keep a close eye on what’s happening in the bicycle market. For decades the trends have shifted back and forth between sleek road models and beefier off-roaders. There have been boom years here and there for the dealers and manufacturers, but nothing like what the bike industry is experiencing now with the arrival of e-bikes on the market. Driven primarily by electrification, micromobility ridership (which includes conventional bikes and scooters) has grown more than 50-fold over the last 10 years. Projections suggest the market’s value will be $300 billion by 2030.
It doesn’t take an MBA with a major in marketing to understand the broad appeal of electrification. Most adults have ridden a bicycle as children, but several decades of gap years has left many of them with a level of fitness that makes pedaling against the wind or up any incline difficult and unappealing. An e-bike can put even the least fitness conscious back in the saddle and open the options for outdoor recreation they haven’t dreamed of since childhood.
In large part the people flocking to e-bikes are retiree’s who thought they were “over the hill.” They are having so much fun they don’t care if the Lycra-clad “serious” cyclists notice the battery bulge in the frame on their e-bikes. Another group of e-bike adopters are motivated by the “greenness” of a fossil-fuel–free electric powered transportation which, with minimal compromise, can be used as they would a car around town and for longer commutes than they would have considered on a purely pedal-powered bicycle.
Unfortunately, there is a growing group of younger e-bike riders who are motivated and uninhibited by the potential that the power boost of a small electric motor can provide. And here is where the ugliness begins to intrude on what was otherwise a beautiful and expanding landscape. However, it is the young who are, not surprisingly, drawn to the speed, and with any vehicle – motorized or conventional – as speed increases so does the frequency and seriousness of accidents.
The term e-bike covers a broad range of vehicles, from those designated class 1, which require pedaling and are limited to 20 miles per hour, to class 3, which may have a throttle and unmodified can hit 28 mph. Class 2 bikes have a throttle that will allow the rider to reach 20 mph without pedaling. Modifying any class of e-bike can substantially increase its speed, but this is more common in classes 2 and 3. As an example, some very fast micromobiles are considered unclassified e-bikes and avoid being labeled motorcycles simply because they have pedals.
One has to give some credit to the e-bike industry for eventually adopting this classification system. But, we must give the rest of us, including parents and public safety officials, a failing grade for doing a poor job of translating these scores into enforceable regulations to protect both riders and pedestrians from serious injury.
On the governmental side only a little more than half of US states have used the three category classification to craft their regulations. Many jurisdictions have failed to differentiate between streets, sidewalks, and trails. Regulations vary from state to state, and many states leave it up to local communities. From my experience chairing our town’s Bicycle and Pedestrian Advisory Committee, I can tell you that even “progressive” communities are struggling to decide who can ride what where. The result has been that people of all ages, but mostly adolescents, are traveling on busy streets and sidewalks at speeds that put themselves and pedestrians at risk.
On the parental side of the problem are families that have either allowed or enabled their children to ride class 2 and 3 e-bikes without proper safety equipment or consideration for the safety of the rest of the community. Currently, this is not much of a problem here in Maine thanks to the weather and the high price of e-bikes. However, I frequently visit an affluent community in the San Francisco Bay Area, where it is not uncommon to see middle school children speeding along well in excess of 20 mph.
Unfortunately this is another example, like television and cell phone, in which our society has been unable to keep up with technology by molding the behavior of our children and/or creating enforceable rules that allow us to reap the benefits of new discoveries while minimizing the collateral damage that can accompany them.
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 pdnews@mdedge.com.
Bicycles have been woven into my life since I first straddled a hand-me-down with a fan belt drive when I was 3. At age 12 my friend Ricky and I took a 250 mile–plus 2-night adventure on our 3-speed “English” style bikes. We still marvel that our parents let us do it when neither cell phones nor GPS existed.
I have always bike commuted to work, including the years when that involved a perilous navigation into Boston from the suburbs. In our mid-50s my wife and I biked from Washington state back here to Maine with another couple unsupported. We continue to do at least one self-guided cycle tour out of the country each year.
Not surprisingly, I keep a close eye on what’s happening in the bicycle market. For decades the trends have shifted back and forth between sleek road models and beefier off-roaders. There have been boom years here and there for the dealers and manufacturers, but nothing like what the bike industry is experiencing now with the arrival of e-bikes on the market. Driven primarily by electrification, micromobility ridership (which includes conventional bikes and scooters) has grown more than 50-fold over the last 10 years. Projections suggest the market’s value will be $300 billion by 2030.
It doesn’t take an MBA with a major in marketing to understand the broad appeal of electrification. Most adults have ridden a bicycle as children, but several decades of gap years has left many of them with a level of fitness that makes pedaling against the wind or up any incline difficult and unappealing. An e-bike can put even the least fitness conscious back in the saddle and open the options for outdoor recreation they haven’t dreamed of since childhood.
In large part the people flocking to e-bikes are retiree’s who thought they were “over the hill.” They are having so much fun they don’t care if the Lycra-clad “serious” cyclists notice the battery bulge in the frame on their e-bikes. Another group of e-bike adopters are motivated by the “greenness” of a fossil-fuel–free electric powered transportation which, with minimal compromise, can be used as they would a car around town and for longer commutes than they would have considered on a purely pedal-powered bicycle.
Unfortunately, there is a growing group of younger e-bike riders who are motivated and uninhibited by the potential that the power boost of a small electric motor can provide. And here is where the ugliness begins to intrude on what was otherwise a beautiful and expanding landscape. However, it is the young who are, not surprisingly, drawn to the speed, and with any vehicle – motorized or conventional – as speed increases so does the frequency and seriousness of accidents.
The term e-bike covers a broad range of vehicles, from those designated class 1, which require pedaling and are limited to 20 miles per hour, to class 3, which may have a throttle and unmodified can hit 28 mph. Class 2 bikes have a throttle that will allow the rider to reach 20 mph without pedaling. Modifying any class of e-bike can substantially increase its speed, but this is more common in classes 2 and 3. As an example, some very fast micromobiles are considered unclassified e-bikes and avoid being labeled motorcycles simply because they have pedals.
One has to give some credit to the e-bike industry for eventually adopting this classification system. But, we must give the rest of us, including parents and public safety officials, a failing grade for doing a poor job of translating these scores into enforceable regulations to protect both riders and pedestrians from serious injury.
On the governmental side only a little more than half of US states have used the three category classification to craft their regulations. Many jurisdictions have failed to differentiate between streets, sidewalks, and trails. Regulations vary from state to state, and many states leave it up to local communities. From my experience chairing our town’s Bicycle and Pedestrian Advisory Committee, I can tell you that even “progressive” communities are struggling to decide who can ride what where. The result has been that people of all ages, but mostly adolescents, are traveling on busy streets and sidewalks at speeds that put themselves and pedestrians at risk.
On the parental side of the problem are families that have either allowed or enabled their children to ride class 2 and 3 e-bikes without proper safety equipment or consideration for the safety of the rest of the community. Currently, this is not much of a problem here in Maine thanks to the weather and the high price of e-bikes. However, I frequently visit an affluent community in the San Francisco Bay Area, where it is not uncommon to see middle school children speeding along well in excess of 20 mph.
Unfortunately this is another example, like television and cell phone, in which our society has been unable to keep up with technology by molding the behavior of our children and/or creating enforceable rules that allow us to reap the benefits of new discoveries while minimizing the collateral damage that can accompany them.
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 pdnews@mdedge.com.
Doctor I-Don’t-Know
Many, many years ago there was a Thanksgiving when as I was just beginning to earn a reputation in my wife’s family. There were no place cards on the table and the usual hovering and jockeying seats was well underway. From behind me I heard one of my young nieces pipe up: “I want to sit next to Doctor I-don’t-know.”
After a few words of negotiation we were all settled in our places and ready to enjoy our meal. It took only a few seconds of introspection for me to grasp how I had received that moniker, which some physicians might consider disrespectful.
I was the only physician within several generations of that family and, as such, my in-laws thought it only appropriate to ask me medical questions. They courteously seemed to avoid personal questions about their own health and were particularly careful not to roll up their sleeves or unbutton their shirts to show me a lesion or a recently acquired surgical scar. No, my wife’s family members were curious. They wanted answers to deeper questions, the hard science so to speak. “How does aspirin work?” was a typical and painful example. Maybe pharmacologists today have better answers but 40 years ago I’m not so sure; I certainly didn’t know back then and would reply, “I don’t know.” Probably for the third or fourth time that day.
Usually I genuinely didn’t know the answer. However, sometimes my answer was going to be so different from the beliefs and biases of my inquisitor that, in the interest of expediency, “I don’t know” seemed the most appropriate response.
If you were reading Letters from Maine 25 years ago, that scenario might sound familiar. I have chosen to pull it out of the archives as a jumping-off point for a consideration of the unfortunate example some of us set when the COVID pandemic threw a tsunami of unknowns at us. Too many physician-“experts” were afraid to say, “I don’t know.” Instead, and maybe because, they themselves were afraid that the patients couldn’t handle the truth that none of us in the profession knew the correct answers. When so many initial pronouncements proved incorrect, it was too late to undo the damage that had been done to the community’s trust in the rest of us.
It turns out that my in-laws were not the only folks who thought of me as Doctor I-don’t-know. One of the perks of remaining in the same community after one retires is that encounters with former patients and their parents happen frequently. On more than one occasion a parent has thanked me for admitting my ignorance. Some have even claimed that my candid approach was what they remembered most fondly. And, that quality increased their trust when I finally provided an answer.
There is an art to delivering “I don’t know.” Thirty years ago I would excuse myself and tell the family I was going to my office to pull a book off the shelf or call a previous mentor. Now one only needs to ask Dr. Google. No need to leave the room. If appropriate, the provider can swing the computer screen so that the patient can share in the search for the answer.
That strategy only works when the provider merely needs to update or expand his/her knowledge. However, there are those difficult situations when no one could know the answer given the current parameters of the patient’s situation. More lab work might be needed. It may be too early in the trajectory of the patient’s illness for the illnesses signs and symptoms to declare themselves.
In these situations “I don’t know” must be followed by a “but.” It is what comes after that “but” and how it is delivered that can convert the provider’s admission of ignorance into a demonstration of his or her character. Is he/she a caring person trying to understand the patient’s concerns? Willing to enter into a cooperative relationship as together they search for the cause and hopefully for a cure for the patient’s currently mysterious illness?
I recently read about a physician who is encouraging medical educators to incorporate more discussions of “humility” and its role in patient care into the medical school and postgraduate training curricula. He feels, as do I, that
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 pdnews@mdedge.com.
Many, many years ago there was a Thanksgiving when as I was just beginning to earn a reputation in my wife’s family. There were no place cards on the table and the usual hovering and jockeying seats was well underway. From behind me I heard one of my young nieces pipe up: “I want to sit next to Doctor I-don’t-know.”
After a few words of negotiation we were all settled in our places and ready to enjoy our meal. It took only a few seconds of introspection for me to grasp how I had received that moniker, which some physicians might consider disrespectful.
I was the only physician within several generations of that family and, as such, my in-laws thought it only appropriate to ask me medical questions. They courteously seemed to avoid personal questions about their own health and were particularly careful not to roll up their sleeves or unbutton their shirts to show me a lesion or a recently acquired surgical scar. No, my wife’s family members were curious. They wanted answers to deeper questions, the hard science so to speak. “How does aspirin work?” was a typical and painful example. Maybe pharmacologists today have better answers but 40 years ago I’m not so sure; I certainly didn’t know back then and would reply, “I don’t know.” Probably for the third or fourth time that day.
Usually I genuinely didn’t know the answer. However, sometimes my answer was going to be so different from the beliefs and biases of my inquisitor that, in the interest of expediency, “I don’t know” seemed the most appropriate response.
If you were reading Letters from Maine 25 years ago, that scenario might sound familiar. I have chosen to pull it out of the archives as a jumping-off point for a consideration of the unfortunate example some of us set when the COVID pandemic threw a tsunami of unknowns at us. Too many physician-“experts” were afraid to say, “I don’t know.” Instead, and maybe because, they themselves were afraid that the patients couldn’t handle the truth that none of us in the profession knew the correct answers. When so many initial pronouncements proved incorrect, it was too late to undo the damage that had been done to the community’s trust in the rest of us.
It turns out that my in-laws were not the only folks who thought of me as Doctor I-don’t-know. One of the perks of remaining in the same community after one retires is that encounters with former patients and their parents happen frequently. On more than one occasion a parent has thanked me for admitting my ignorance. Some have even claimed that my candid approach was what they remembered most fondly. And, that quality increased their trust when I finally provided an answer.
There is an art to delivering “I don’t know.” Thirty years ago I would excuse myself and tell the family I was going to my office to pull a book off the shelf or call a previous mentor. Now one only needs to ask Dr. Google. No need to leave the room. If appropriate, the provider can swing the computer screen so that the patient can share in the search for the answer.
That strategy only works when the provider merely needs to update or expand his/her knowledge. However, there are those difficult situations when no one could know the answer given the current parameters of the patient’s situation. More lab work might be needed. It may be too early in the trajectory of the patient’s illness for the illnesses signs and symptoms to declare themselves.
In these situations “I don’t know” must be followed by a “but.” It is what comes after that “but” and how it is delivered that can convert the provider’s admission of ignorance into a demonstration of his or her character. Is he/she a caring person trying to understand the patient’s concerns? Willing to enter into a cooperative relationship as together they search for the cause and hopefully for a cure for the patient’s currently mysterious illness?
I recently read about a physician who is encouraging medical educators to incorporate more discussions of “humility” and its role in patient care into the medical school and postgraduate training curricula. He feels, as do I, that
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 pdnews@mdedge.com.
Many, many years ago there was a Thanksgiving when as I was just beginning to earn a reputation in my wife’s family. There were no place cards on the table and the usual hovering and jockeying seats was well underway. From behind me I heard one of my young nieces pipe up: “I want to sit next to Doctor I-don’t-know.”
After a few words of negotiation we were all settled in our places and ready to enjoy our meal. It took only a few seconds of introspection for me to grasp how I had received that moniker, which some physicians might consider disrespectful.
I was the only physician within several generations of that family and, as such, my in-laws thought it only appropriate to ask me medical questions. They courteously seemed to avoid personal questions about their own health and were particularly careful not to roll up their sleeves or unbutton their shirts to show me a lesion or a recently acquired surgical scar. No, my wife’s family members were curious. They wanted answers to deeper questions, the hard science so to speak. “How does aspirin work?” was a typical and painful example. Maybe pharmacologists today have better answers but 40 years ago I’m not so sure; I certainly didn’t know back then and would reply, “I don’t know.” Probably for the third or fourth time that day.
Usually I genuinely didn’t know the answer. However, sometimes my answer was going to be so different from the beliefs and biases of my inquisitor that, in the interest of expediency, “I don’t know” seemed the most appropriate response.
If you were reading Letters from Maine 25 years ago, that scenario might sound familiar. I have chosen to pull it out of the archives as a jumping-off point for a consideration of the unfortunate example some of us set when the COVID pandemic threw a tsunami of unknowns at us. Too many physician-“experts” were afraid to say, “I don’t know.” Instead, and maybe because, they themselves were afraid that the patients couldn’t handle the truth that none of us in the profession knew the correct answers. When so many initial pronouncements proved incorrect, it was too late to undo the damage that had been done to the community’s trust in the rest of us.
It turns out that my in-laws were not the only folks who thought of me as Doctor I-don’t-know. One of the perks of remaining in the same community after one retires is that encounters with former patients and their parents happen frequently. On more than one occasion a parent has thanked me for admitting my ignorance. Some have even claimed that my candid approach was what they remembered most fondly. And, that quality increased their trust when I finally provided an answer.
There is an art to delivering “I don’t know.” Thirty years ago I would excuse myself and tell the family I was going to my office to pull a book off the shelf or call a previous mentor. Now one only needs to ask Dr. Google. No need to leave the room. If appropriate, the provider can swing the computer screen so that the patient can share in the search for the answer.
That strategy only works when the provider merely needs to update or expand his/her knowledge. However, there are those difficult situations when no one could know the answer given the current parameters of the patient’s situation. More lab work might be needed. It may be too early in the trajectory of the patient’s illness for the illnesses signs and symptoms to declare themselves.
In these situations “I don’t know” must be followed by a “but.” It is what comes after that “but” and how it is delivered that can convert the provider’s admission of ignorance into a demonstration of his or her character. Is he/she a caring person trying to understand the patient’s concerns? Willing to enter into a cooperative relationship as together they search for the cause and hopefully for a cure for the patient’s currently mysterious illness?
I recently read about a physician who is encouraging medical educators to incorporate more discussions of “humility” and its role in patient care into the medical school and postgraduate training curricula. He feels, as do I, that
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 pdnews@mdedge.com.
The Mysterious Latch
While there may be some lactation consultants who disagree, in my experience counseling women attempting to breastfeed is more art than science. Well before the American Academy of Pediatrics (AAP) began to offer mini courses on breastfeeding for practitioners I was left to help new mothers based on watching my wife nurse our three children and what scraps of common sense I could sweep up off the floor.
Using my own benchmarks of success I would say I did a decent job with dyads who sought my help. I began by accepting that even under optimal conditions, not every woman and/or child can successfully breastfeed. None of the infants died or was hospitalized with dehydration. A few may have required some additional phototherapy, but they all completed infancy in good shape. On the maternal side I am sure there were a few mothers who had lingering feelings of inadequacy because they had “failed” at breastfeeding. But, for the most part, I think I succeeded in helping new mothers remain as mentally healthy as they could be given the rigors of motherhood. At least I gave it my best shot.
If I had a strategy, it was a focus on maintaining a routine (schedule can have an ugly aura about it) that allowed mothers to achieve spells of restorative rest. Helping mothers with the difficult task of deciding whether their infant was hungry, or tired, or uncomfortable was always a struggle, but well worth the effort when we succeeded. Finally, I tried to help mothers step back off the ledge and look at the bigger picture — breastfeeding was not the only way to feed their baby while we were working to overcome the bumps in the road.
Where I failed was in my inability to effectively counsel when it came to the mysteries of the latch. In large part it was because I was a man and helping the dyad succeed at latching on to the breast can require a hands-on approach with which I felt a bit uncomfortable. I could certainly test a baby’s suck and oral architecture with my pinky but otherwise I had to rely on women to help if latching was a problem. I think even trained lactation consultants have difficulty with this mysterious process, which is completely hidden from view inside the baby’s mouth.
Fortunately for me and the dyads I was working with, we rarely considered ankyloglossia as a problem. My training had been that tongue-tie seldom, if ever, contributed to speech problems and even less commonly hindered latch. I think I recall snipping a couple of lingual frenulums early in my career in a bloodless and seemingly painless procedure. But, for the life of me I can’t recall the motivation. It may have been that the ankyloglossia was so obvious that I couldn’t convince the parents it would resolve or it was at the request of a lactation consultant.
But, obviously after I stopped seeing newborns a decade and a half ago the lingual frenulum became a target of surgical assault with, at times, unfortunate results that made breastfeeding painful and more difficult. It’s hard for me to imagine why anyone would consider using a laser for such a simple procedure. But, then I haven’t invested in a laser that allowed me to charge $800 for the procedure. I doubt I even charged for it. It wouldn’t have been worth the time and effort to look up the code. But, then, technology and money can be powerful motivators.
The good news is the AAP has been watching and recently issued a clinical report in which they state what many of us have known from personal observation — They further note that “the symptoms of ankyloglossia overlap those of other breastfeeding difficulties.”
So there you have it. Another fad has been squashed and we’ve come full circle. The latch still remains mystery hidden from view. I think we have to suspect that there exists a small number of dyads in which tongue-tie creates a problem with nursing. And, there may be some safe imaging technique coming along that gives us a glimpse of what happens in the dark recesses of a nursing baby’s mouth. Until then we must rely on masters of the art of lactation consulting, the “Latch Whisperers.”
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 pdnews@mdedge.com.
While there may be some lactation consultants who disagree, in my experience counseling women attempting to breastfeed is more art than science. Well before the American Academy of Pediatrics (AAP) began to offer mini courses on breastfeeding for practitioners I was left to help new mothers based on watching my wife nurse our three children and what scraps of common sense I could sweep up off the floor.
Using my own benchmarks of success I would say I did a decent job with dyads who sought my help. I began by accepting that even under optimal conditions, not every woman and/or child can successfully breastfeed. None of the infants died or was hospitalized with dehydration. A few may have required some additional phototherapy, but they all completed infancy in good shape. On the maternal side I am sure there were a few mothers who had lingering feelings of inadequacy because they had “failed” at breastfeeding. But, for the most part, I think I succeeded in helping new mothers remain as mentally healthy as they could be given the rigors of motherhood. At least I gave it my best shot.
If I had a strategy, it was a focus on maintaining a routine (schedule can have an ugly aura about it) that allowed mothers to achieve spells of restorative rest. Helping mothers with the difficult task of deciding whether their infant was hungry, or tired, or uncomfortable was always a struggle, but well worth the effort when we succeeded. Finally, I tried to help mothers step back off the ledge and look at the bigger picture — breastfeeding was not the only way to feed their baby while we were working to overcome the bumps in the road.
Where I failed was in my inability to effectively counsel when it came to the mysteries of the latch. In large part it was because I was a man and helping the dyad succeed at latching on to the breast can require a hands-on approach with which I felt a bit uncomfortable. I could certainly test a baby’s suck and oral architecture with my pinky but otherwise I had to rely on women to help if latching was a problem. I think even trained lactation consultants have difficulty with this mysterious process, which is completely hidden from view inside the baby’s mouth.
Fortunately for me and the dyads I was working with, we rarely considered ankyloglossia as a problem. My training had been that tongue-tie seldom, if ever, contributed to speech problems and even less commonly hindered latch. I think I recall snipping a couple of lingual frenulums early in my career in a bloodless and seemingly painless procedure. But, for the life of me I can’t recall the motivation. It may have been that the ankyloglossia was so obvious that I couldn’t convince the parents it would resolve or it was at the request of a lactation consultant.
But, obviously after I stopped seeing newborns a decade and a half ago the lingual frenulum became a target of surgical assault with, at times, unfortunate results that made breastfeeding painful and more difficult. It’s hard for me to imagine why anyone would consider using a laser for such a simple procedure. But, then I haven’t invested in a laser that allowed me to charge $800 for the procedure. I doubt I even charged for it. It wouldn’t have been worth the time and effort to look up the code. But, then, technology and money can be powerful motivators.
The good news is the AAP has been watching and recently issued a clinical report in which they state what many of us have known from personal observation — They further note that “the symptoms of ankyloglossia overlap those of other breastfeeding difficulties.”
So there you have it. Another fad has been squashed and we’ve come full circle. The latch still remains mystery hidden from view. I think we have to suspect that there exists a small number of dyads in which tongue-tie creates a problem with nursing. And, there may be some safe imaging technique coming along that gives us a glimpse of what happens in the dark recesses of a nursing baby’s mouth. Until then we must rely on masters of the art of lactation consulting, the “Latch Whisperers.”
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 pdnews@mdedge.com.
While there may be some lactation consultants who disagree, in my experience counseling women attempting to breastfeed is more art than science. Well before the American Academy of Pediatrics (AAP) began to offer mini courses on breastfeeding for practitioners I was left to help new mothers based on watching my wife nurse our three children and what scraps of common sense I could sweep up off the floor.
Using my own benchmarks of success I would say I did a decent job with dyads who sought my help. I began by accepting that even under optimal conditions, not every woman and/or child can successfully breastfeed. None of the infants died or was hospitalized with dehydration. A few may have required some additional phototherapy, but they all completed infancy in good shape. On the maternal side I am sure there were a few mothers who had lingering feelings of inadequacy because they had “failed” at breastfeeding. But, for the most part, I think I succeeded in helping new mothers remain as mentally healthy as they could be given the rigors of motherhood. At least I gave it my best shot.
If I had a strategy, it was a focus on maintaining a routine (schedule can have an ugly aura about it) that allowed mothers to achieve spells of restorative rest. Helping mothers with the difficult task of deciding whether their infant was hungry, or tired, or uncomfortable was always a struggle, but well worth the effort when we succeeded. Finally, I tried to help mothers step back off the ledge and look at the bigger picture — breastfeeding was not the only way to feed their baby while we were working to overcome the bumps in the road.
Where I failed was in my inability to effectively counsel when it came to the mysteries of the latch. In large part it was because I was a man and helping the dyad succeed at latching on to the breast can require a hands-on approach with which I felt a bit uncomfortable. I could certainly test a baby’s suck and oral architecture with my pinky but otherwise I had to rely on women to help if latching was a problem. I think even trained lactation consultants have difficulty with this mysterious process, which is completely hidden from view inside the baby’s mouth.
Fortunately for me and the dyads I was working with, we rarely considered ankyloglossia as a problem. My training had been that tongue-tie seldom, if ever, contributed to speech problems and even less commonly hindered latch. I think I recall snipping a couple of lingual frenulums early in my career in a bloodless and seemingly painless procedure. But, for the life of me I can’t recall the motivation. It may have been that the ankyloglossia was so obvious that I couldn’t convince the parents it would resolve or it was at the request of a lactation consultant.
But, obviously after I stopped seeing newborns a decade and a half ago the lingual frenulum became a target of surgical assault with, at times, unfortunate results that made breastfeeding painful and more difficult. It’s hard for me to imagine why anyone would consider using a laser for such a simple procedure. But, then I haven’t invested in a laser that allowed me to charge $800 for the procedure. I doubt I even charged for it. It wouldn’t have been worth the time and effort to look up the code. But, then, technology and money can be powerful motivators.
The good news is the AAP has been watching and recently issued a clinical report in which they state what many of us have known from personal observation — They further note that “the symptoms of ankyloglossia overlap those of other breastfeeding difficulties.”
So there you have it. Another fad has been squashed and we’ve come full circle. The latch still remains mystery hidden from view. I think we have to suspect that there exists a small number of dyads in which tongue-tie creates a problem with nursing. And, there may be some safe imaging technique coming along that gives us a glimpse of what happens in the dark recesses of a nursing baby’s mouth. Until then we must rely on masters of the art of lactation consulting, the “Latch Whisperers.”
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 pdnews@mdedge.com.
Is Parenthood Losing Its Appeal?
A recent survey by the Pew Research Center has found that among adults younger than 50, the percentage who say they are unlikely to have children rose from 37% to 47%. With this trend freshly etched in my consciousness, I stumbled across an interview with Anastasia Berg, an assistant professor of philosophy at the University of California, Irvine. Professor Berg and Rachel Wiseman have just published What Are Children For? On Ambivalence and Choice. How could a pediatrician with time on his hands ignore a provocative title like that?
I was immediately drawn to Professor Berg’s observations about the “concerns, anxieties, and lines of reasoning people encounter when considering whether or not they should have children.” Prior to the 1960s, motherhood seemed to just be a natural progression from marriage. That’s the way my wife and I approached it when we had our first child while I was in my last year of medical school in 1971. There was no discussion of the pros and cons, except maybe that financially waiting until the eve of my first professional paycheck seemed to make sense.
However, as Professor Berg points out, from the 1960s up until well into the 1980s, as feminist thought gained a higher profile, there were anti-motherhood factions. There were others who wanted to see motherhood reformed and adapted so it “could once again be a legitimate source of meaning and value in life.” However, both camps agreed that the choice to have children was a decision that “women should make completely on their own.”
Now, well into the new millennium, we are looking at a completely different landscape. In the past, having children was woven into the fabric of human life in which we had a past, a present, and a role in creating the future. Professor Berg observes that currently, having children is often considered a project, not unlike our other projects such as “career choice or travel plans.” What are the pluses and minuses?
The Pew Survey found that 60% of adults younger than 50 who don’t have children said that not having children made it less difficult to be successful and have an active social life. Many felt that being a parent would improve the chances of having someone to care for you as you aged.
When my wife and I considered the financial costs of motherhood more than 50 years ago, our calculation was primarily about the timing. The decision to have a second child focused our concern around our ability to balance our attention between two siblings. A third child just sorta happened without any discussion.
Professor Berg echoes the Pew findings when she observes that currently woman are considering the cost in terms of their identities. Will motherhood transform me? Will there be a cost not only to my career but also to all the associations, interests, and activities I have accumulated? These costs are likely to be greater the longer the decision to have a child is put off. She adds that viewing motherhood as a transformation can make the decision to have children scarier than it needs to be. My wife and I, at age 26 and 27, were still in the early stages of building our identities. My wife had a 2-year college degree and no career plans on the horizon. Having a child was one of those things that was built into who we became.
But to compare our experiences in the 1970s to the realities of the first quarter of the 21st century ignores the concerns facing today’s adults who are facing the cloud of uncertainty hanging over all of us. Despite their claims to fix the situation, both sides of the political spectrum are leveraging fear to gain our support. Even climate change skeptics must have some concern in the spate of natural disasters we are experiencing. Not to mention the pandemic. Anxiety in this country is at an all time high. Optimism doesn’t seem to fit into today’s journalists’ lexicon, as they chose to focus on conflict instead of cooperation. It’s hard to question any adult who harbors serious doubts on taking on the challenge of parenthood and bringing a child into a world that feels unsettled.
However, based on her research and her own experience as a parent, Professor Berg offers some advice. She encourages people to think and discuss the decision to have children earlier in their life trajectory, before they have made decisions that may eventually limit their options. Second, she discourages making a list of pros and cons. Finally, she advises taking a long view and ask yourself whether you “choose to take a direct part in ushering in the next generation.”
Sounds like advice that will optimize the chances of making the good decision about having a child. I’m just thankful to have lived at time and in a situation when having child was just the thing most married couples did.
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 pdnews@mdedge.com.
A recent survey by the Pew Research Center has found that among adults younger than 50, the percentage who say they are unlikely to have children rose from 37% to 47%. With this trend freshly etched in my consciousness, I stumbled across an interview with Anastasia Berg, an assistant professor of philosophy at the University of California, Irvine. Professor Berg and Rachel Wiseman have just published What Are Children For? On Ambivalence and Choice. How could a pediatrician with time on his hands ignore a provocative title like that?
I was immediately drawn to Professor Berg’s observations about the “concerns, anxieties, and lines of reasoning people encounter when considering whether or not they should have children.” Prior to the 1960s, motherhood seemed to just be a natural progression from marriage. That’s the way my wife and I approached it when we had our first child while I was in my last year of medical school in 1971. There was no discussion of the pros and cons, except maybe that financially waiting until the eve of my first professional paycheck seemed to make sense.
However, as Professor Berg points out, from the 1960s up until well into the 1980s, as feminist thought gained a higher profile, there were anti-motherhood factions. There were others who wanted to see motherhood reformed and adapted so it “could once again be a legitimate source of meaning and value in life.” However, both camps agreed that the choice to have children was a decision that “women should make completely on their own.”
Now, well into the new millennium, we are looking at a completely different landscape. In the past, having children was woven into the fabric of human life in which we had a past, a present, and a role in creating the future. Professor Berg observes that currently, having children is often considered a project, not unlike our other projects such as “career choice or travel plans.” What are the pluses and minuses?
The Pew Survey found that 60% of adults younger than 50 who don’t have children said that not having children made it less difficult to be successful and have an active social life. Many felt that being a parent would improve the chances of having someone to care for you as you aged.
When my wife and I considered the financial costs of motherhood more than 50 years ago, our calculation was primarily about the timing. The decision to have a second child focused our concern around our ability to balance our attention between two siblings. A third child just sorta happened without any discussion.
Professor Berg echoes the Pew findings when she observes that currently woman are considering the cost in terms of their identities. Will motherhood transform me? Will there be a cost not only to my career but also to all the associations, interests, and activities I have accumulated? These costs are likely to be greater the longer the decision to have a child is put off. She adds that viewing motherhood as a transformation can make the decision to have children scarier than it needs to be. My wife and I, at age 26 and 27, were still in the early stages of building our identities. My wife had a 2-year college degree and no career plans on the horizon. Having a child was one of those things that was built into who we became.
But to compare our experiences in the 1970s to the realities of the first quarter of the 21st century ignores the concerns facing today’s adults who are facing the cloud of uncertainty hanging over all of us. Despite their claims to fix the situation, both sides of the political spectrum are leveraging fear to gain our support. Even climate change skeptics must have some concern in the spate of natural disasters we are experiencing. Not to mention the pandemic. Anxiety in this country is at an all time high. Optimism doesn’t seem to fit into today’s journalists’ lexicon, as they chose to focus on conflict instead of cooperation. It’s hard to question any adult who harbors serious doubts on taking on the challenge of parenthood and bringing a child into a world that feels unsettled.
However, based on her research and her own experience as a parent, Professor Berg offers some advice. She encourages people to think and discuss the decision to have children earlier in their life trajectory, before they have made decisions that may eventually limit their options. Second, she discourages making a list of pros and cons. Finally, she advises taking a long view and ask yourself whether you “choose to take a direct part in ushering in the next generation.”
Sounds like advice that will optimize the chances of making the good decision about having a child. I’m just thankful to have lived at time and in a situation when having child was just the thing most married couples did.
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 pdnews@mdedge.com.
A recent survey by the Pew Research Center has found that among adults younger than 50, the percentage who say they are unlikely to have children rose from 37% to 47%. With this trend freshly etched in my consciousness, I stumbled across an interview with Anastasia Berg, an assistant professor of philosophy at the University of California, Irvine. Professor Berg and Rachel Wiseman have just published What Are Children For? On Ambivalence and Choice. How could a pediatrician with time on his hands ignore a provocative title like that?
I was immediately drawn to Professor Berg’s observations about the “concerns, anxieties, and lines of reasoning people encounter when considering whether or not they should have children.” Prior to the 1960s, motherhood seemed to just be a natural progression from marriage. That’s the way my wife and I approached it when we had our first child while I was in my last year of medical school in 1971. There was no discussion of the pros and cons, except maybe that financially waiting until the eve of my first professional paycheck seemed to make sense.
However, as Professor Berg points out, from the 1960s up until well into the 1980s, as feminist thought gained a higher profile, there were anti-motherhood factions. There were others who wanted to see motherhood reformed and adapted so it “could once again be a legitimate source of meaning and value in life.” However, both camps agreed that the choice to have children was a decision that “women should make completely on their own.”
Now, well into the new millennium, we are looking at a completely different landscape. In the past, having children was woven into the fabric of human life in which we had a past, a present, and a role in creating the future. Professor Berg observes that currently, having children is often considered a project, not unlike our other projects such as “career choice or travel plans.” What are the pluses and minuses?
The Pew Survey found that 60% of adults younger than 50 who don’t have children said that not having children made it less difficult to be successful and have an active social life. Many felt that being a parent would improve the chances of having someone to care for you as you aged.
When my wife and I considered the financial costs of motherhood more than 50 years ago, our calculation was primarily about the timing. The decision to have a second child focused our concern around our ability to balance our attention between two siblings. A third child just sorta happened without any discussion.
Professor Berg echoes the Pew findings when she observes that currently woman are considering the cost in terms of their identities. Will motherhood transform me? Will there be a cost not only to my career but also to all the associations, interests, and activities I have accumulated? These costs are likely to be greater the longer the decision to have a child is put off. She adds that viewing motherhood as a transformation can make the decision to have children scarier than it needs to be. My wife and I, at age 26 and 27, were still in the early stages of building our identities. My wife had a 2-year college degree and no career plans on the horizon. Having a child was one of those things that was built into who we became.
But to compare our experiences in the 1970s to the realities of the first quarter of the 21st century ignores the concerns facing today’s adults who are facing the cloud of uncertainty hanging over all of us. Despite their claims to fix the situation, both sides of the political spectrum are leveraging fear to gain our support. Even climate change skeptics must have some concern in the spate of natural disasters we are experiencing. Not to mention the pandemic. Anxiety in this country is at an all time high. Optimism doesn’t seem to fit into today’s journalists’ lexicon, as they chose to focus on conflict instead of cooperation. It’s hard to question any adult who harbors serious doubts on taking on the challenge of parenthood and bringing a child into a world that feels unsettled.
However, based on her research and her own experience as a parent, Professor Berg offers some advice. She encourages people to think and discuss the decision to have children earlier in their life trajectory, before they have made decisions that may eventually limit their options. Second, she discourages making a list of pros and cons. Finally, she advises taking a long view and ask yourself whether you “choose to take a direct part in ushering in the next generation.”
Sounds like advice that will optimize the chances of making the good decision about having a child. I’m just thankful to have lived at time and in a situation when having child was just the thing most married couples did.
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 pdnews@mdedge.com.
It’s the Television, Stupid
As more and more of us begin to feel (or believe we are feeling) the symptoms of aging, our language has begun to incorporate new words and phrases such as “aging in place” or “healthy aging.” In fact, some scientists have created a diagnostic criteria to define “healthy aging.” If you have reached your 70th birthday without mental health issues, memory issues, physical impairments, or chronic disease, according to some researchers at T.H. Chan School of Public Health and Brigham and Women’s Hospital, you should receive a gold star for healthy aging.
I am now nearly a decade past that milestone and can’t remember where I’ve put my gold star, or even if I had ever received one. But, I get up each morning looking forward to another day of activity and feeling “pretty good.”
Healthy aging is not something you start doing when you turn 65. Aging is something that goes on from the moment you are born. For the first couple decades we call it “maturing.” If you have lived well, the odds are you will age well. And, for that reason we should take note of some recent work by Boston-based researchers.
Looking at recent data from 45,000 participants in the well-known Nurses Health Study, the investigators found that for every 2-hour increase in daily sedentary behavior, the participants cut their chances of healthy aging by 12%. On the other hand, for every 2 hours of light physical activity, they increased their odds of healthy aging by 6 %.
There are two important messages sitting just below the surface of these two observations. First, we continue to overemphasize the importance of “exercise” in our attempt to help our patients achieve wellness. The word “exercise” carries with it whole carousel full of baggage including “fitness programs,” gym memberships, pulse rate monitors, pain, sweat, and spandex, to name just a few. Exercise can conjure up bad memories of suiting up for phys ed class, group showers, and being picked last when teams were being chosen.
It turns out the we should simply be promoting activity, and light activity at that — vacuuming the living room, walking around the block, rearranging the books on your bedroom book shelf, making a pot of soup, doing the laundry. Just getting up off one’s behind and doing something instead of being a passive spectator.
This somewhat counterintuitive notion of the benefit of light activity is beginning to get more attention. Earlier this year, I reported on a study by Andre O. Abaje MD, MPH, in which he showed that light physical activity in children was superior to more vigorous activity in lowering lipids.
The more important message embedded in this paper based on the Nurses Health Study is that the researchers used television watching time as their proxy for sedentary behavior. The investigators chose TV viewing because it is ubiquitous and includes prolonged sitting. Being semi-reclined on the couch or in a lounger requires very little muscle activity, which is in turn linked to disruption of glucose metabolism, increased inflammation, and altered blood flow to the brain, to name just a few of its collateral damages. I would add that TV viewing often prompts viewers to stay up well beyond their healthy bedtime. And, we know sleep deprivation is not compatible with health aging.
A traditional warning issued to new retirees was once “Don’t let the old rocking chair get ya.” In fact, I wonder how many folks watching television even have or use wood rocking chairs anymore, which, if rocked, might qualify as a light exercise if the viewer made the effort to rock. Instead I suspect most television viewing is done cocooned in soft recliners or curled up on a couch.
I will admit that this recent paper merely supports a suspicion I have harbored for decades. Like many of you, I have wondered how our society got to the point where obesity is frequent enough to be labeled a disease, attention deficit diagnoses are becoming increasingly prevalent, and our life expectancy is shrinking. There are dozens of factors, but if I had to pick one, I would paraphrase James Carville’s advice to Bill Clinton: “It’s the television, stupid.”
At least a couple of notches above “Are you wearing your seatbelt?” It can start with a nonjudgmental question such as “What are your favorite television shows?” And then deftly move toward compiling a tally of how many hours the patient watches each day.
How you manage the situation from there is up to you and can be based on the patient’s complaints and problem list. You might suggest he or she start by eliminating 2 hours of viewing a day. Then ask if he or she thinks that new schedule is achievable. If they ask for alternatives, be ready with a list of light activities that they might be surprised are healthier than their current behavior. Follow up with another visit or a call to see how they are doing. It’s that important, and your call will underscore your concern.
Sedentism is a serious health problem in this country and our emphasis on encouraging vigorous exercise isn’t working. Selling a television diet will be a tough sell, but it needs to be done.
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 pdnews@mdedge.com.
As more and more of us begin to feel (or believe we are feeling) the symptoms of aging, our language has begun to incorporate new words and phrases such as “aging in place” or “healthy aging.” In fact, some scientists have created a diagnostic criteria to define “healthy aging.” If you have reached your 70th birthday without mental health issues, memory issues, physical impairments, or chronic disease, according to some researchers at T.H. Chan School of Public Health and Brigham and Women’s Hospital, you should receive a gold star for healthy aging.
I am now nearly a decade past that milestone and can’t remember where I’ve put my gold star, or even if I had ever received one. But, I get up each morning looking forward to another day of activity and feeling “pretty good.”
Healthy aging is not something you start doing when you turn 65. Aging is something that goes on from the moment you are born. For the first couple decades we call it “maturing.” If you have lived well, the odds are you will age well. And, for that reason we should take note of some recent work by Boston-based researchers.
Looking at recent data from 45,000 participants in the well-known Nurses Health Study, the investigators found that for every 2-hour increase in daily sedentary behavior, the participants cut their chances of healthy aging by 12%. On the other hand, for every 2 hours of light physical activity, they increased their odds of healthy aging by 6 %.
There are two important messages sitting just below the surface of these two observations. First, we continue to overemphasize the importance of “exercise” in our attempt to help our patients achieve wellness. The word “exercise” carries with it whole carousel full of baggage including “fitness programs,” gym memberships, pulse rate monitors, pain, sweat, and spandex, to name just a few. Exercise can conjure up bad memories of suiting up for phys ed class, group showers, and being picked last when teams were being chosen.
It turns out the we should simply be promoting activity, and light activity at that — vacuuming the living room, walking around the block, rearranging the books on your bedroom book shelf, making a pot of soup, doing the laundry. Just getting up off one’s behind and doing something instead of being a passive spectator.
This somewhat counterintuitive notion of the benefit of light activity is beginning to get more attention. Earlier this year, I reported on a study by Andre O. Abaje MD, MPH, in which he showed that light physical activity in children was superior to more vigorous activity in lowering lipids.
The more important message embedded in this paper based on the Nurses Health Study is that the researchers used television watching time as their proxy for sedentary behavior. The investigators chose TV viewing because it is ubiquitous and includes prolonged sitting. Being semi-reclined on the couch or in a lounger requires very little muscle activity, which is in turn linked to disruption of glucose metabolism, increased inflammation, and altered blood flow to the brain, to name just a few of its collateral damages. I would add that TV viewing often prompts viewers to stay up well beyond their healthy bedtime. And, we know sleep deprivation is not compatible with health aging.
A traditional warning issued to new retirees was once “Don’t let the old rocking chair get ya.” In fact, I wonder how many folks watching television even have or use wood rocking chairs anymore, which, if rocked, might qualify as a light exercise if the viewer made the effort to rock. Instead I suspect most television viewing is done cocooned in soft recliners or curled up on a couch.
I will admit that this recent paper merely supports a suspicion I have harbored for decades. Like many of you, I have wondered how our society got to the point where obesity is frequent enough to be labeled a disease, attention deficit diagnoses are becoming increasingly prevalent, and our life expectancy is shrinking. There are dozens of factors, but if I had to pick one, I would paraphrase James Carville’s advice to Bill Clinton: “It’s the television, stupid.”
At least a couple of notches above “Are you wearing your seatbelt?” It can start with a nonjudgmental question such as “What are your favorite television shows?” And then deftly move toward compiling a tally of how many hours the patient watches each day.
How you manage the situation from there is up to you and can be based on the patient’s complaints and problem list. You might suggest he or she start by eliminating 2 hours of viewing a day. Then ask if he or she thinks that new schedule is achievable. If they ask for alternatives, be ready with a list of light activities that they might be surprised are healthier than their current behavior. Follow up with another visit or a call to see how they are doing. It’s that important, and your call will underscore your concern.
Sedentism is a serious health problem in this country and our emphasis on encouraging vigorous exercise isn’t working. Selling a television diet will be a tough sell, but it needs to be done.
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 pdnews@mdedge.com.
As more and more of us begin to feel (or believe we are feeling) the symptoms of aging, our language has begun to incorporate new words and phrases such as “aging in place” or “healthy aging.” In fact, some scientists have created a diagnostic criteria to define “healthy aging.” If you have reached your 70th birthday without mental health issues, memory issues, physical impairments, or chronic disease, according to some researchers at T.H. Chan School of Public Health and Brigham and Women’s Hospital, you should receive a gold star for healthy aging.
I am now nearly a decade past that milestone and can’t remember where I’ve put my gold star, or even if I had ever received one. But, I get up each morning looking forward to another day of activity and feeling “pretty good.”
Healthy aging is not something you start doing when you turn 65. Aging is something that goes on from the moment you are born. For the first couple decades we call it “maturing.” If you have lived well, the odds are you will age well. And, for that reason we should take note of some recent work by Boston-based researchers.
Looking at recent data from 45,000 participants in the well-known Nurses Health Study, the investigators found that for every 2-hour increase in daily sedentary behavior, the participants cut their chances of healthy aging by 12%. On the other hand, for every 2 hours of light physical activity, they increased their odds of healthy aging by 6 %.
There are two important messages sitting just below the surface of these two observations. First, we continue to overemphasize the importance of “exercise” in our attempt to help our patients achieve wellness. The word “exercise” carries with it whole carousel full of baggage including “fitness programs,” gym memberships, pulse rate monitors, pain, sweat, and spandex, to name just a few. Exercise can conjure up bad memories of suiting up for phys ed class, group showers, and being picked last when teams were being chosen.
It turns out the we should simply be promoting activity, and light activity at that — vacuuming the living room, walking around the block, rearranging the books on your bedroom book shelf, making a pot of soup, doing the laundry. Just getting up off one’s behind and doing something instead of being a passive spectator.
This somewhat counterintuitive notion of the benefit of light activity is beginning to get more attention. Earlier this year, I reported on a study by Andre O. Abaje MD, MPH, in which he showed that light physical activity in children was superior to more vigorous activity in lowering lipids.
The more important message embedded in this paper based on the Nurses Health Study is that the researchers used television watching time as their proxy for sedentary behavior. The investigators chose TV viewing because it is ubiquitous and includes prolonged sitting. Being semi-reclined on the couch or in a lounger requires very little muscle activity, which is in turn linked to disruption of glucose metabolism, increased inflammation, and altered blood flow to the brain, to name just a few of its collateral damages. I would add that TV viewing often prompts viewers to stay up well beyond their healthy bedtime. And, we know sleep deprivation is not compatible with health aging.
A traditional warning issued to new retirees was once “Don’t let the old rocking chair get ya.” In fact, I wonder how many folks watching television even have or use wood rocking chairs anymore, which, if rocked, might qualify as a light exercise if the viewer made the effort to rock. Instead I suspect most television viewing is done cocooned in soft recliners or curled up on a couch.
I will admit that this recent paper merely supports a suspicion I have harbored for decades. Like many of you, I have wondered how our society got to the point where obesity is frequent enough to be labeled a disease, attention deficit diagnoses are becoming increasingly prevalent, and our life expectancy is shrinking. There are dozens of factors, but if I had to pick one, I would paraphrase James Carville’s advice to Bill Clinton: “It’s the television, stupid.”
At least a couple of notches above “Are you wearing your seatbelt?” It can start with a nonjudgmental question such as “What are your favorite television shows?” And then deftly move toward compiling a tally of how many hours the patient watches each day.
How you manage the situation from there is up to you and can be based on the patient’s complaints and problem list. You might suggest he or she start by eliminating 2 hours of viewing a day. Then ask if he or she thinks that new schedule is achievable. If they ask for alternatives, be ready with a list of light activities that they might be surprised are healthier than their current behavior. Follow up with another visit or a call to see how they are doing. It’s that important, and your call will underscore your concern.
Sedentism is a serious health problem in this country and our emphasis on encouraging vigorous exercise isn’t working. Selling a television diet will be a tough sell, but it needs to be done.
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 pdnews@mdedge.com.