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Saturday, December 31, 2011

Top Ten Tips for positive parenting in 2012

Number 2.  Be "Exclusive": More on the How and Why of Breastfeeding

Happily, more and more mothers are making the choice to breastfeed their newborns. But for many, this is a short-lived success, soon giving way to unplanned weaning to the bottle.  Why is this?  The number one cause of breastfeeding failure is unnecessary formula supplementation during the first days and weeks of life.

I am incredibly proud that our hospital has doubled the rate of newborns that breastfeed exclusively during their hospital stay.  This is as important as it is difficult.  We live in a culture where "more is better" and where our tolerance for inconvenience is, well, limited.  So, it is tempting for relatives, and doctors, and nurses to say..."go ahead.  Give a bottle.  Top off the tank.  You'll get a little more rest and hey, the extra calories won't hurt the baby..."

But here's the problem.  Those occasional bottles mean a little less breastfeeding, which means a little less milk production and a little less practice for the mother and infant, which means a little less success, which means a couple of MORE bottles, and off we go.  By the second office visit, a back of the envelope calorie count tells the pediatrician that baby is getting pretty much all her calories from Meade Johnson Corporation and not from mom.

Spread the word.  Breastfeeding is incredibly important to health.  And exclusivity, especially at the start, can make the critical difference to breastfeeding success.  

I want to wish a happy and health New Year to all my readers.   Number 1 in the Top Ten Tips for Positive Parenting in 2012 appears New Year's Day!

Friday, December 30, 2011

Top Ten Tips for positive parenting in 2012

Number 3.  Breastfeed Your Infant

In 2011, the US Surgeon General issued a "Call to Action" in which she noted that 

"The health effects of breastfeeding are well recognized... Breast milk is uniquely suited to the human infant’s nutritional needs and is a live substance with unparalleled immunological and anti-inflammatory properties that protect against a host of illnesses and diseases for both mothers and children.

"The report [by the federal Agency for Healthcare Research and Quality] reaffirmed the health risks associated with formula feeding and early weaning from breastfeeding. With regard to short-term risks, formula feeding is associated with increases in common childhood infections, such as diarrhea and ear infections. The risk of acute ear infection, also called acute otitis media, is 100 percent higher among exclusively formula-fed infants than in those who are exclusively breastfed during the first six months."

The same report goes on to cite other documented health risks of formula feeding, including an increased risk of severe lower respiratory tract infections, asthma, obesity, type 2 diabetes, and, relative to breastfed infants, increased incidence of leukemia and sudden infant death syndrome.  Maternal outcome studies also favor the choice to breastfeed, with formula-feeding mothers suffering increased rates of breast and ovarian cancers.

Breastfeeding is among the best ways to give a gift of health to infants and mothers alike. I can think of no more important decision that expectant parents can make, beating out in utero classical music, multi-media baby toys and all manner of nursery renovations.  More on this shortly!

Monday, December 26, 2011

Top Ten Tips for positive parenting in 2012

Number 4. Give your child and yourself the gift of the natural world.

Standing on the bare ground, — my head bathed by the blithe air, and uplifted into infinite space, — all mean egotism vanishes. I become a transparent eye-ball; I am nothing; I see all; the currents of the Universal Being circulate through me; I am part or particle of God.  -- Ralph Waldo Emerson

The direct experience of Nature has inspired writers, philosophers, poets and painters for many generations.   Like the gift of Music,  Nature has the capacity to touch us, adult and child alike, at many levels.  The pure sensation of cool sand between our toes and the blue green glitter of ocean water on a summer morning...the bracing cold air, the burning in our thighs, and the grandeur of a New England mountaintop vista achieved by a brisk hike in winter...these and a thousand other experiences are within our reach.  Whether, as parents and partners in wonder, we embark on small excursions to cleanse our lungs and our minds, or to unburden ourselves of life's stresses and traumas, or to strengthen our legs and our hearts, or, like Emerson, to search for transcendental meaning and connectedness with All that Is, the Nature in our own backyard is deserving of our attention as parents and as citizens of the planet.    I believe that Joy in nature is, itself, most likely "natural."   But habitual choices that insulate us from the world - web browsing over walking,  shopping malls* over spring meadows - inevitably dull our senses and our capacity to meet Nature on her own terms.    And so the act of introducing our children to the larger world cannot begin early enough.  There's a New Year's resolution of 2012! 

(*It is the height of irony that our local Walt Whitman Mall is named for one of Emerson's compatriots and the most famous transcendentalist poet in our nation's history, an individual who would have had some interesting and critical things to say about the culture that keeps his namesake enterprise full of young people, even on sunny days!)

Sunday, December 25, 2011

Merry Christmas to All

Second Opinion is on holiday today for the observance of Christmas, following an evening of delicious fishes, fine wines and the company of family.  To paraphrase Oscar Wilde, "All things in moderation, including moderation!"

Friday, December 23, 2011

Top Ten Tips for positive parenting in 2012

Number 5.  There's a secret to bringing up a healthy, happy, confident teenager.

...And when someone tells me what it is, I promise to post it here first!

Seriously, life is much too complicated for "one size fits all" solutions.  One thing is clear: teenagers face more life stresses than ever before, and one can make a pretty good case that in 2012 it will be at least as hard to be a 16 year old than to be an adult.  At the moment, one teenager I know is worrying about preparing a concert, writing the equivalent of a college thesis, taking final exams and finishing a half dozen college applications in about as many days.  All of this while finding some time for friends, food and sleep.

It seems to me that in these times the best parents must be full of thoughtful contradiction.  We have to be flexible, but also consistent.  We need to support our kids' efforts at independence while providing a safety net from seriously bad decisions. We have to be really good listeners, but not try to be a peer. We need to encourage our teenagers to strive for excellence, but make it clear that we will not love them less when  they fail.  Finally, we need to know when to spur them on and when to suggest that they pump the brakes.  In other words, we need to help them find and value balance in their lives.

Well, speaking of centeredness, just 39 hours until Christmas morning.  Last minute shopping anyone?  Best wishes to all in the Season of Peace!

For more on this, check out the American Academy of Pediatrics website at...

Tuesday, December 20, 2011

Top Ten Tips for positive parenting in 2012

Number 6.  Remember the ABCs of safe infant sleeping.

A parent puts a seemingly healthy four month old infant boy to sleep, and the baby never wakes up.  There is no greater tragedy.

Since the early 1990's the incidence of Sudden Infant Death Syndrome has declined dramatically - from almost 1.5 cases per 1000 live births to less than a third of that number.   This decline has been attributed to  several practices that comprise the "A, B, C's" of safe sleeping.  Here they are.

"A" is for alone. Infants should not "co-sleep" with a parent in their bed, because this has been associated with "overlying" and consequent suffocation.

"B" is for back.  Infants should go to sleep for naps and at night on their backs.  It turns out that one of five infants who die from SIDS are in the care of someone other than their parents, and have been placed on their tummies -- "unaccustomed" prone position for sleep appears to be especially dangerous.  It is also advised that infants not be placed on their sides at the time of sleep, because of the risk of rolling onto their stomach.  Is it EVER safe for babies to be on their tummies?  Absolutely!  Tummy time (while awake) is important for encouraging muscle development and proper head shape.

"C" is for crib.   Infants should never be put to sleep on couches or on any bedding that is not infant-safe.  Not only is there a risk for falls, but soft, cushioned surfaces increase the risk of overheating and blockage of the airway, leading to the buildup of carbon dioxide.

One more point - mothers should avoid smoking during pregnancy and infants should NOT be exposed to second hand tobacco smoke, because both have been associated with an increased risk of SIDS.  For more, go to

Five shopping days till Christmas.  (When I look at my credit card activity, why do I feel like I'm running my own personal stimulus package??) Happy Holidays to All!!

Saturday, December 17, 2011

Study Demonstrates That Under-insured (Sometimes) Receive Better Care

The take-away:  uninsured children receive more appropriate antibiotic prescriptions than those with private  insurance.  For those red staters who fear that the "less is more" argument proffered by healthcare gurus is a cover for "socialistic healthcare rationing" in an imagined Obama-Berwick dystopia, here is something to think about...

In the December issue of the journal PEDIATRICS, Adam Hirsch and colleagues report that privately insured patients are significantly more likely to receive antimicrobial treatment when none is indicated, and also more likely to receive broad-spectrum agents when the selection of narrow-spectrum antibiotics (or symptomatic treatment alone) conforms more closely to evidence-based guidelines.

Additionally, patients with the lowest co-payments for their prescriptions were most likely to receive inappropriate therapy.  Not only do these "overuse" errors generate waste in the system, but they also drive antibiotic resistance patterns in the community, and expose children to avoidable complications, such as drug allergy and antibiotic-associated diarrheal disease including that caused by Clostridium difficile.

It would be over-reaching to infer from all this that under-insured patients receive better healthcare overall: there are more than enough data to demonstrate the reverse.  However,  this "man bites dog" story of care disparities does serve to remind us that we have enormous opportunities to improve care by "doing less."

Monday, December 12, 2011

Top Ten Tips for Positive Parenting in 2012

Number 7.  Just Say No (or Occasionally Yes or Maybe) to Antibiotics for Your Child.   Alexander Fleming's discovery in 1928 that a natural product of the penicillium mold had potent anti-bacterial properties saved millions of lives, created an industry and changed human history.   Some eighty years later, we continue to enjoy the benefits of penicillin and those of dozens of compounds that have been created to mimic its effects.  At the same time, the use of antibiotics for conditions that are unlikely to benefit from these drugs can expose children to unwarranted risk, spread resistant bacteria in the community, and create unnecessary costs for families and the healthcare system overall.

Conditions for which antibiotics are generally not appropriate include nasal discharge for less than 10-14 days, croup, bronchitis and sore throat in children without laboratory evidence of streptococcal infection.  All of these conditions occur commonly in childhood and are typically caused by respiratory viruses.

For other conditions, antibiotic treatment is absolutely appropriate.  Antibiotics are prescribed to treat infections typically caused by bacteria where treatment shortens the course of illness, reduces spread, or prevents complications.   Examples of minor infections for which this holds include streptococcal sore throat, urinary tract infection and some skin infections.  Experts advise that the physician selects the narrowest-spectrum antibiotic known to be effective for the problem at hand.  (The treatment of serious infections in hospitalized children is an important, but separate, topic; more on that another time!)

Finally, there are a few conditions for which antibiotics may or may not be warranted.  In 2004, the American Academy of Pediatrics published a guideline emphasizing that middle ear infections ("acute otitis media") usually cleared without antibiotics and suggested that certain children could be considered for observation and symptomatic treatment alone.  Another such condition is pneumonia in otherwise healthy toddlers.  The majority of lung infections in young children are caused by viruses.  This is especially likely if the onset is gradual, disease severity is mild,  the infection seems to involve both lungs, and certain laboratory findings are present.

Before I sign off, let me try to dispel a couple of myths.  Here's one: "prescribing antibiotics hurts the immune system."  This a one of the medical tough love myths, like "if I don't get Johnny those glasses, his eyes will get stronger."  Both sound good, but neither is true.   And one more, for balance.  Rather than a mythical side effect, here's a mythical benefit:  "Doc, I know you said antibiotics aren't good for a cold, but he has a [football game/school dance/final exam/trip to Sweden] next week and we need him to be over this."  We really do hear this a lot.  I am pretty sure, however, that antibiotics are as ineffective against colds prior to a football game as they are against colds coming on at other times.

With all of this confusion, let me leave you with something simple.  Information is the best medicine.  Ask your trusted pediatrician about prescribing - or not prescribing - antibiotics to your child.

Friday, December 9, 2011

A Night of Revelry and Compassion in Action

Last evening, more than 300 revelers in glittering formalwear packed Oheka Castle for Huntington Hospital’s annual Gala.  There was a Joan Rivers impersonator, a lively auction (with an authentic auctioneer), delicious food and more different forms of chocolate than I’ve seen in a long time.  Spirits soared, the dance floor rocked and generous donors dug deep in their wallets to help hospital leaders realize a  plan to create a new kind of patient care unit, one built very consciously to promote a vision of patient and family centered care for the 21st century.


“Illness is the night-side of life,” writes author Susan Sontag, “a more onerous citizenship. Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick.  Although we all prefer to use only the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.”

Sontag’s characterization of the experience of illness resonates for every person who has occupied a hospital bed, or sat at the bedside of a loved one in the throes of severe illness.  At those times, we are gripped in turn by feelings of discomfort, dislocation, fear, anxiety, impatience, lack of control and anger. 

Under the worst of circumstances, the professionals rushing in and out of the room seem to inhabit another world altogether, citizens, as it were, of the “kingdom of the well.”  Forging and sustaining an empathic connection with patients and families is central to our identity as health professionals, and among our most solemn obligations.  We want to be present for our patient. How can we physicians and nurses do this, consistently and well?   

Patient “experience of care” data are now ubiquitous.  Every hospital in the country looks at these, and devotes resources to improving the results.  Not only that: as a result of publicly available on-line “report cards” community members can see how their local hospital compares with others.  Back at the hospital, front line professionals, administrators and Board members are reviewing this information and reacting to it.  And so it should be: such surveys results are the “unfiltered voice” of our community.  Presenting the data on dashboards, alongside hospital length of stay and “days cash on hand” we convey to one another that our interactions with patients may be understood, in their aggregate, as an operations problem, susceptible to good management.  Are we right?

Jerome Lowenstein, Professor of Medicine at NYU Medical Center hints at another perspective on the problem in his powerful essay, “Can You Teach Compassion?” To illustrate the issue, he catalogues the litany of “facts” that comprised the standard social history on the urban, university hospital teaching service where he attends, a place where everyone knows that an IVDA means an “intravenous drug abuser,” and where all interns have been taught a “formula” to efficiently report on their patients in units of chemical consumption: x pack-years, y quarts-per-day, z bags of heroin…

“This is the first NYU admission for this 35 year old IVDA…” 

It is dangerous to disrupt any entrenched social order, and the hospital staff is unmistakably a society unto itself.  And so this physician’s efforts are especially noteworthy.  One day, he interrupts the intern with a challenge :

“Would our thinking or care be different if you began by telling us that this is a 35 year old Marine veteran who has been addicted to drugs since he served, with valor, in Viet Nam?

With this brief, poignant observation Lowenstein illustrates the profound influence of the patient’s story – of Narrative – on our understanding of the patient, and ourselves, and, by extension, on the delivery of compassionate, patient and family-centered healthcare generally.   More on this another time.  Next installment:  Item number 7 on our countdown of tips for “Positive Parenting in 2012.”


Wednesday, December 7, 2011

Top ten tips for positive parenting in 2012

Number 8:

Make music a part of your child's life!

A large body of literature has confirmed that music education for children confers benefits on cognitive development across multiple domains.  A recent comparative study performed at Long Island University found:

"...positive associations between music education and increased abilities in non-musical (eg, linguistic, mathematical, and spatial) domains in children...Because neural response to music is a widely distributed system within the brain…. it would not be unreasonable to expect that some processing networks for music and language behaviors, namely reading, located in both hemispheres of the brain would overlap.”

There is more to music than its influence on neural networks, however.  As children grow, the making of music in groups involves them in an increasingly complex and subtle give and take, building advanced listening skills, interaction at many levels and the ability to collaborate.  Achieving something beautiful as the result of hard long work enhances confidence and self-esteem.

But even these salutary effects are not why I, personally, feel so strongly about music and childhood.  Does anyone remember Robin Williams' role in The Dead Poets' Society? There was a scene in his classroom when, in a passionate attempt to shake his pupils into spiritual wakefulness he said something like, "We have doctors to help people live long lives, but it's the artist who gives those lives meaning."  Music is a means to many ends, but the gift of music to our children needs no point, and no justification, other than itself.  

Tuesday, December 6, 2011

Number 9:

1.     Immunize your child and promote childhood immunization.  If your infant is six months of age or more, get her immunized against the flu every year.   Currently, experts recommend that children receive protection against hepatitis (A and B), diphtheria, whooping cough, tetanus, meningitis-causing bacteria (H. influenzae, N.meningiditis and S. pneumoniae), rotavirus, measles, mumps, German measles, chicken pox, influenza and human papillomavirus.   None of these vaccines are recommended for any reason OTHER than the fact that each and every one of these diseases can lead to death or permanent harm.   It saddens me to recall that I have personally cared for infants and children who have died from preventable meningitis.  I helped run the (unsuccessful) "code" on a boy with chicken pox whose heart stopped when fluid collected around his heart.  And I cared for another school-aged child who lapsed into coma and later succumbed to encephalitis due to influenza.  This, I'm afraid to say, is a very partial list.  

      Lately we've seen a large number of whooping cough cases in Huntington township.  Many were in unimmunized children.  In other cases, it was because unimmunized persons served as the "lit match" to start an outbreak that also affected individuals who received vaccine but whose immune system did not fully protect them.   You see, if pretty much everyone gets immunized, then everyone benefits.  

      The current level of public skepticism about vaccines is of deep concern to the healthcare community.  Somehow, fiction is becoming accepted "fact" by some, while a few strident spokespersons are shouting down the calmer but worried voices of vaccine experts and child health advocates.  What to do?  Go to the CDC and AAP websites and tour the sections on immunization. Write down your questions. Talk to your pediatrician.  Unfortunately, there is no such option as "deciding not to decide." Not immunizing IS a decision. And a serious one.

      Next installment will feature some lightness of being! Promise!  I'm thinking...Music and Children.   Hoping your Season is full of wonder...

Monday, December 5, 2011

Top ten tips for positive parenting in 2012

1.       Number 10: 

      No TV in your child’s bedroom!    OK, so TV sounds so...last week.  (What about other kinds of tube time?  Does Skyping count?) Nonetheless, television time strongly correlates with childhood obesity.  Conversely, even light physical activity is of help in promoting healthy weight.  According to a 2011 Statement by the American Academy of Pediatrics:  

      There are a number of ways that watching TV could be contributing to obesity: (1) increased sedentary activity and displacement of more physical pursuits; (2) unhealthy eating practices learned from both the programming and the advertisements for unhealthy foods; (3) increased snacking behavior while viewing; and (4) interference with normal sleep patterns. However, most researchers now agree that the evidence linking excessive TV-viewing and obesity is persuasive.

        I once attended an exhibit where Sony was showing off the newest HD technology.  One visitor effused that "it's so clear that you can see every blade of grass."  Another attendee piped up, "If you want to see a blade of grass," he said," I recommend going outside!"  Amen to that.