children

Conflict Resolution in Parenting: Prevention

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CinemaUsher-01A good friend of mine, not realizing how complex a subject it was, and how much work it would be, asked me to write a blog about conflict resolution.

He may no longer be on my good list (coal for Christmas, you!), but for the next few weeks I will be blogging about conflict resolution because he got me thinking. This week is for the groundwork: exploring the issues that are at the root of many conflicts between parents. Next week will be about the most (and least) effective ways to fix those conflicts; after that we can expand into parent-child conflicts and those between children.

The first, most important, and absolutely non-negotiable concrete foundation of conflict resolution between parents is that parents are equal partners, and have to respect each other as such. You chose to have a child together. It is the privilege and responsibility of both to parent. It does not matter if you are married, partners, or single, or if one parent is taller, stronger, richer, smarter, more talented…. That child belongs to both of you and needs both of you. I once saw a child in the post office with a parent on either side holding onto an arm and pulling. Don’t do that. Your child is not a rope in a tug of war.

Conflicts can only be resolved by compromise. If one side wholly wins, the other has no choice but to keep fighting. Both sides have to give a little; both have to feel that they have won something. None of us are always right; we can afford to be flexible. In the end it is far more important that your children see that their parents respect each other, can listen to each other and discuss problems, and are able to compromise, than whether or not their bedtime can be changed, or they can go to a party.

If parents cannot respect each other as equals, that is the lesson their child will absorb, and someday he or she might accept something less than respect from their partner.

The structure we build on that foundation is agreement on common goals. It seems, going into parenting, that we should all have the same obvious goals. We want our child alive, healthy, happy, self-confident… Obvious, yes? It’s amazing how much variation there is within these bounds. Ideally, parents discuss and agree on goals for their children before they actually have any. In reality, many parents discuss religion and not much else.

So, ten things to talk about with your partner before things go ka-BOOM:

  1. Where you will live: Having a child is a lifetime commitment, so this means 20 years of where you will live, not just right now. Talk about location, type of home, whether you want to be near family, if you will move for a better job…  whatever is important to you. Things change, and it is nice to know where your partner stands on the subject ahead of time.
  2. Finance: Children need security to feel safe enough to explore and grow. Financial worries can plant their lives on shifting sands. Sit down together and figure out how much money you make, what you will spend it on, and how you will save for an emergency and the future. Make a budget. Your child does not want to loose a parent over the electric bill.
  3. Diet: You want them to be healthy, right? Not to have diabetes at 12, back pain at 15, and heart disease at 40? That means agreeing on what to feed them, and on being a good example yourself. It also includes not using food for emotional support or rewards. And don’t get me started on using food so that your child will like you better than the other parent.
  4. Routines and schedules: How obsessive are you going to be about homework, meal times, and bedtime routines? Routines can be incredibly helpful: kids don’t argue over something (like bedtime) that is a habit. On the other hand, routines can become rigid and squash all random opportunities and creativity. Where do  you put that balance? Routines work only if both parents are in agreement on them, so talk.
  5. Sleeping arrangements: I have seen more than a few marriages end in an ugly divorce over this one. There is really no moral right or wrong on it, but you must both agree. Just don’t co-sleep with a baby under 6 months. I’ve lost two small patients that way, and never want to lose another. Just don’t.
  6. Education: How important is school? (Guess which side I took on this one) Are some subjects more important than others? Do actual grades and the particular school matter, or is it learning and inspiration that is important? How about learning technical skills versus book learning? How about “useful” skills versus not so obviously useful? Did I mention that I also have an a degree in anthropology? I am married to an engineer. We have discussions.
  7. Careers: Which career choices are acceptable, and which are not? You might want to write these down and then switch lists – surprise! When I was a child, my options were nurse, teacher, or housewife. My mother had crossed “nun” off the list and not replaced it with anything. I was a big surprise.
  8. Athletics: How important are sports? Life ending? Or just done to be well rounded and get exercise? Any particular sport in mind?
  9. Criminal behavior: This is a biggie. Children start out as small barbarians, travel through self-involved, and wander into insecure before they become adults. They will try out hitting, biting, lying and stealing along the way. How will you react? What will you do to discourage this behavior?
  10. Privacy: Children have no legal right to privacy. They have what you give them, and they deserve your protection from their own … lack of insight, so their privacy cannot be absolute. Where is that line? How much do you trust before you verify?

So, I have managed to write a blog on conflict resolution without ever discussing how to resolve a conflict. Hmm. We will do that next week. First and foremost: respect your partner and set common goals. Once you have that foundation and framework, everything else falls into place more easily. With a little nudge. Or two.

Build that foundation. If parents endlessly argue and fight, marriages self destruct; if parents cannot treat each other with respect and decide on common goals, children self destruct.

Have that conversation before you need it.

Letting Go: Being a Parent

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boy with baloon2-01Many parenting issues seem to be all about control. Parents make rules and then enforce them; cook food and convince the children to eat it; educate young minds and teach them right from wrong. Being a parent brings with it a mountain of responsibility, and the authority needed to do the job.

I’ve been thinking lately about the other side of the coin. What role does letting go of that control play in parenting?

When we are pregnant or our progeny are small, we are completely responsible for those small creations, and we make all of the decisions about their lives. Remember the terrifying responsibility of holding a tiny, fragile new being in your arms? At least that small person didn’t argue with you over the necessity of being in a car seat, or sleeping on their back! Later, we put their small arms and legs into clothes we like, and hold their hands as we walk them to the dance or art class we choose. We choose the home in which they grow, the religion they practice, and the school they attend.

Somewhere along the line that absolute control begins to evaporate, we loosen our grip and our children begin to choose their own direction.

Perhaps it starts with that first strident “No!” to the clothes we have chosen, or evolves later with a demand to take a course in auto mechanics instead of ballet. Perhaps they refuse to study in a class they hate, or ask to go to their friend’s church instead of yours.

They become increasingly independent, take on more responsibility for their own lives, and our influence wanes.

Life itself has more of an impact than we would sometimes choose. Disappointments and loss are inevitable, and possibly essential for normal development. Nothing can make a parent feel more powerless than when a child is injured or sick. Heartbreak strengthens our souls and allows us to appreciate real love later, but it is hard to watch it happen to the one you never wanted to see hurt.

Worse, how do you manage when your child is simply not built in a way that coincides with their dreams? When they are not tall enough, or pretty enough, or talented enough, and they have to realign their futures to a different reality? How, when random chance throws them sideways? There is sometimes simply nothing in your parenting arsenal that will help.

How do you manage when, in order to build their future, they have to leave another part of their lives (perhaps the part in which you are standing) behind?

They will never know who they truly are and be able to choose the direction of their lives if we dictate all of their decisions. So we as parents need to learn to step back and empower them, rather than holding all that power close ourselves. We need to allow them to risk hurt, while we place the weight of their lives on their own shoulders, so that they can become our equals rather than our dependents.

Over time, we assume more of a supporting role. We are there if they need love, if they ask for help, or if they want to bounce ideas, but we no longer determine and fix their lives. Powerlessness is proof of successful parenting.

So, letting go.

Perhaps we start when we hold up two outfits and ask them which one they want to wear. We keep control of the things that keep them safe, making them wear seat belts and bike helmets, locking up guns, making them get their shots – but let them choose which sport they want to play, what they want to learn, and who they want to associate with. We let them fail a test or loose a friend, even though we can see it coming and they cannot. We protect them from choices that will destroy their future (drugs, sex, destructive relationships…), but accept their decisions in other areas. It is their life, not ours.

We force ourselves to let go, and step back. We will no doubt be angry, or sad, over some of  their choices. We may feel guilty when they fail and we could have helped. We will have trouble finding where the line is, where that point is that we need to step back.

I have no clear answers, no surety of right and wrong. The most important thing is simply to be conscious of what we are doing, and why we are doing it – to realize that our impact as parents is as great for what we choose not to do as it is for what we do.
Domestic Momster

Pesticides: Not a Major Food Group

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bleach boy-01A recent statement from the American Academy of Pediatrics suggested that we should limit our children’s exposure to pesticides.

It turns out that chemicals designed to kill insects and rodents are not good for children. Who knew?

In large doses, pesticides cause acute poisonings, with symptoms including dizziness, nausea, headaches, twitching or weakness. Smaller doses over a longer time can harm your child’s brain or hormonal systems. When pesticides injure a child’s brain they can cause developmental delays, and attention and behavior problems. Hormonal effects can impact your child’s growth and perhaps his or her reproductive ability. We do need to limit our children’s exposure!

Children are more vulnerable to poisons than adults, not less. Their bodies are actively growing and maturing and are thus easier to damage, like a gymnast caught mid leap. They have faster metabolisms: their hearts beat more quickly and their lungs breathe more rapidly, allowing chemicals in more quickly and in larger amounts. Also, their protective systems aren’t mature and don’t work as well as those of adults to stop the damage.

So, how do we lower children’s exposure in our day-to-day lives? The most common place for your child to ingest pesticides is in the food that they eat, particularly the fruits and vegetables. This does not mean they can skip their veggies! Just wash them first, eat a variety of different produce (different vegies have different amounts of pesticides), and buy organic when you can. Your local farm stand is, of course, your best friend.

Children are also exposed to pesticides in their homes and yards, so we may need to make some changes there. Keep all of your household pest products in their original containers with child proof caps intact. Just today I had a child drink a degreaser because her mom had stored it in a soda bottle! Store poisons out of reach and out of sight in a locked cupboard. If you are using a pesticide and the phone rings, close the container and put it out of reach while you are out of visual range. I have seen more than a few kids poisoned when mom went to see why the baby was crying, or to answer the door. Kids are quick.

Read and follow the directions on the container. Use pesticides only when there is a problem, never to just prevent one. Less is always better. When you do use them, use crevice and crack treatments, not bombs. Think about how your kids live on the surfaces to which you are applying the treatment: kids lie on the ground, crawl under things, and touch stuff and put their hands in their mouths. Don’t put the rat poison behind the couch – your 2 year old will find it. My amazing, brilliant grandchild found the mouse poison behind the dishwasher. World’s worst grandma.

Change your clothes after you use pesticides, and store your shoes outside.

If you have a wooden play structure that was built between 1970 and 2004 and not made of cedar or redwood, the wood was probably treated with chromated copper arsenate. Arsenic also is not good for children, so you may want to replace the structure.

Read the ingredients on lawn and garden products and any pet products. Organophosphates (most commonly malathion, but there are dozens) were banned from home use in 2001, but many people have old products sitting around, or use commercial products at home. They are also still used in public parks and schools.

In America we use more than 1 billion pounds of pesticides every year in our farms, homes and public spaces. Ask what is used by your city and at your child’s school. There are many newer, safer products that have been developed in the last few years, so suggest alternatives and avoid the organophosphates when you can.

Stay safe and be healthy!

What To Do When the Screen Goes Off

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girl with plantMedia addiction in children and the importance of limiting their screen time is a big topic in pediatrics this week.

The American Academy of Pediatrics has always recommended no more than two hours of screen time per day for children over 2 (none for those under 2), and they have lots of data to back that up. Adding to this was a recent study suggesting that toddlers who watched more TV than average were more likely to be bullied later in life: reported bullying went up 11% for each additional hour of TV viewing, over the average of 1 1/2 hours. Scary.

Time spent watching TV is not spent developing social and verbal skills, and not spent using and exercising young bodies.

Children sitting in front of a screen develop a disabling habit of being more passive in their interactions with others.

They put on weight because while they are sitting, with their metabolic rate near what it is when they sleep, they are frequently munching on snack food.

They are more likely to have attention problems because TV teaches them to experience the world in 5 minute pieces.

Last, their perceptions are significantly skewed because they take the behavior of characters and people on TV as normal. Which they are not.

It seems reasonable that since I am one of those pediatricians constantly nagging people to turn off their screens, I have a responsibility to come up with some activities they can do instead. All those hours to fill, and all those useful skills to learn!

Our children need the abilities that excessive TV viewing destroys: social knowledge and the ability to interact with actual humans, verbal skills, an attention span adequate to complete a project, and physical exercise. Let’s throw in knowledge of the real world too, just to be complete.

So, ten things to do after you turn off the TV:

  1. Read a book. I know, it’s obvious, but that doesn’t make it any less important. The most rapid development in the brain’s language and learning centers occurs between 6 months and 3 years of age; we need to take advantage. Just 15 minutes of being read to each day between 6 months and 5 years adds up to 500 hours of reading before they even enter kindergarden, boosting development in these areas. Daily reading in older kids improves their comprehension and speed, in addition to adding to their store of knowledge. Hit that library!
  2. Experiment with science. My all time favorite science site is at Roots of Action. They have experiments in all kinds of science, organized by children’s age and type of science, from astronomy to zoology. There is enough there to keep your kids busy all summer long.
  3. Be creative. Break out the crayons or paints and draw. Make music. Write a story. Perform a theatrical: what kid doesn’t love performing in front of their most supportive audience? Creation exercises and stimulates the brain, making it more imaginative and receptive to new ideas.
  4. Garden. Not only does your munchkin get to play in water, dig in dirt and make a mess, but he or she will also have the pleasure of seeing their plants grow and flower. There is self confidence to be grown along with those beans for diner, and those flowers for the kitchen table. Also, they learn a little responsibility along the way, because they won’t want their precious plants to wither and wilt.
  5. Have a cooking class. Again, you get pride of accomplishment (they peeled those carrots!). They will eat better, because they won’t want their own hard work to go to waste, and they will learn an undeniably necessary skill.
  6. Make a chore list. Exercise, a sense of accomplishment, and lessons on responsibility all wrapped up in one. Give an allowance for completed chores and you can have financial lessons as well.
  7. Play a sport. With them please and have fun, so you have family time and everybody gets some exercise.
  8. Learn a new skill. Summer is the traditional time for classes and camps. Learn to draw, play an instrument, ride a horse… Anything your child has shown an interest in, someone is out there teaching, if you cannot teach it yourself
  9. Volunteer. Aiding others in need will help them appreciate what they have, and will feed their souls. The right sort of volunteer activity can also teach useful skills: Literacy promotion (reading), working with the elderly (communication, patience),  hospital work (medical knowledge), food banks and kitchens (cooking and nutrition), and Habitat (building and repair) are all enriching.
  10. After all this activity, take a backyard vacation. Put out the blow up pool and some beach towels, and drink things with tiny umbrellas. Have a trail hike through the neighborhood with a campout at the end. Have a day in Paris, with a home made Eiffel Tower and a French dictionary. Go to a Broadway show produced by your favorite tiny actors. Backyard vacations are limited only by your imagination, never your wallet.

Who has time for a screen? There is just too much to do! Turn that box off and put away that phone!

Anonymity and Denial in the Twitterverse

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turtle2-01Playwright Tom Stoppard said, “Words are sacred. They deserve respect. If you get the right ones, in the right order, you can nudge the world a little.”

I am old enough to be amazed by social media, with its multitude of words and pictures. It did not exist when I was new. If we wanted enlightenment, we went to the library or read the Post. By the time we found our information, the events were already in the past. We knew people of different cultures existed, and events happened, but it was knowledge that came at a distance, blurred by its time-consuming transformation into letters and pictures.

When we curious children wanted to see what a woman looked like without her clothes, we stole our parent’s National Geographic and leafed through it for pictures of deepest Africa. Kennedy and Lennon were shot, but there were no cell phone videos or instant interviews. The stories unfolded over weeks, with time to adjust and get a little distance.

Social media now comes with immediacy and savage intensity. People’s lives are flayed open and placed on the screen for my perusal. If I presume to know anything about that woman in Africa, she can knock me upside the head minutes later, because she is in reality just a hairsbreadth away. If I pretend to wisdom, the whole world can judge me and let me know where they think are my errors in judgement.

This brilliant transparency should make us more authentic, more determined to write nothing that we would not stand behind to our deaths. We should claim our words without reservation. These words. are. me. Sadly, from a place of weakness and fear it can instead make us deny what we know, as we buffer our truth so as not to be responsible for it.

We write, “Tweets do not replace medical advice, retweets are not to be considered an endorsement.” We backtrack, and pad ourselves against risk. The most powerful thing we can do – put our thoughts into words for other people to see – we disclaim and weaken with “tweets are not meant to be advice.”

Of course they are! What would be the point, otherwise?

If we give thought to and write words down then they need to be true. Words are sacred. We record our words in the hopes that they will “nudge the world a little.” If our words are our truth then they have earned our faith: we have to stand behind them with our names and our identities.

Weakening our words by buying into a fear of lawsuits and judgement is a betrayal of our selves; it costs us a piece of our souls. Our words are us and denying them, even in a small part, allows decay to eat away at our own value.

Conversely, since we wrote those words with our very own minds and hands we should never, in the rush to say something, write down what we know is not truth: those words will also follow us through our lives. People sometimes feel that they can be nasty, petty, or judgmental on the internet because they are anonymous. They can twist the facts just a little to make their point. We must realize that there is no such thing as true anonymity. Even if no one else ever knows who wrote those words, you yourself do.

Persian poet Hafez wrote, “The words you speak become the house you live in.” Write only words that have a strong foundation and the solidity of truth, so that your house is yours alone and can hold up to the hurricane force winds of opinion. Hafez’s words are as true on the internet today as they were in the fourteenth century in ink on paper. Such is the power of words. Believe in them, and in your self.

The Rashes of Summer

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skateboarder-01When the days warm up, pediatric offices see a lot of summer skin problems. Kids aren’t often ill during the summer, but they do get sunburns, bites, jellyfish stings, and rashes.

Sunburn

No one thinks about sunscreen on that first glorious sunshiny day, so sunburns are usually our first evidence that summer is here. Remember to use sunscreen, of course, and don’t forget to reapply it every hour.

If your child does burn, give ibuprofen immediately – it helps with the inflammation and can actually reduce the depth of injury. Use aloe generously: it lessens the pain, moisturizes the skin, and helps heal the damage. If the burn is bad, call your doctor. Prescription steroids and burn creams will help.

Bug Bites

Bug bites are also very popular in the summer, from mosquitos, fire ants, yellow flies, and fleas. Insects inject toxins into children’s skin when they bite; how much a particular child reacts depends on how sensitive he or she is.

Cover up little arms and legs when you can, especially if you are going to be outdoors around twilight. There are excellent clothing treatments available that will keep bugs away and last through several washings, protecting your child indirectly.

If your child is older than 2 months, use insect repellant with DEET on exposed skin, even though it’s nasty. It works and it’s a whole lot better than getting insect borne encephalitis. 10% DEET lasts about 2 hours; 30% lasts about 5 hours. Don’t use anything stronger than 30% on a child. Don’t reapply in the same day, and do wash it off when you go back inside.

Creams with pramoxine or calamine will help with itchiness. Cortisone creams help itch and also swelling and redness, but can only be used a couple of times a day. If there are lots of bites, an antihistamine by mouth will also help with swelling and itch.

Never use antihistamine creams (benadryl is the most common), because children can react to the topical antihistamine and actually get worse instead of better.

Bee stings

Bee and wasp stings are treated much the same way, after making sure to remove the stinger and apply a cool compress (and yes, Grandma’s idea about the wet mud does help).

Poison ivy, oak, and sumac

If your child is a forest dweller, he or she will at some point get poison ivy, oak or sumac. These plants produce a poison called urushiol in their sap and leaves, causing redness, itch and blistering.

The severity of this reaction also varies depending on your munchkin’s sensitivity. My brother’s eyes would swell shut if someone burnt it a block away; I could pull it up and throw it away with no reaction.

Wash both the child and his or her clothes as soon as possible. No lounging on the furniture! The toxin can stay on surfaces for months. Once the toxin is either absorbed into the skin or washed off, the rash is no longer contagious. Blister fluid does not contain urushiol.

The rash will develop first where the most toxin was deposited, in streaks and patches. It can spread for a week or so to the areas where less toxin landed, then take another two weeks to clear.

If the rash is mild, you can treat it at home with cool compresses, baking soda or oatmeal baths, the same creams you used for those pesky bug bites, and that antihistamine by mouth. See? Grandma was right again.

If the rash is not mild, or your child has it on their face, around their eyes, or on their genitals (and how did that plant get there?) call your doc. We can put them on steroids, which help enormously.

Jellyfish stings

If you harbor a small mermaid or man in your home, she or he may get stung by a jellyfish. There are some extremely dangerous jellyfish, so if your child has any trouble breathing, is weak or nauseated, has pain away from the sting, or has sweating, cramping, or diarrhea, call your doctor immediately.

If it is a simple sting, first remove the barbs by scraping it with a towel or a credit card. Don’t rub. Put suntan oil or salt water and hot sand on the sting; heat will deactivate the poison.

Do NOT wash the sting with fresh water – it will make the nematocysts (poison sacks) explode and release more poison into the skin. Your child will scream and not love you anymore. Put only fluids with lots of particles in them on the sting: sting-away, vinegar or steak sauce, for example. Ibuprofen will also help the pain and inflammation.

Allergic rashes

Last, we see allergic reactions to everything from sunscreen to henna tattoos to jewelry to pool chemicals from fun in the sun. Kids with sensitive skin or eczema will rash out in the summer from the heat, humidity and sweat.

By now you can probably sense a common theme (or you could just ask Grandma): give your itchy red bumpy child a cool bath with mild soap. Moisturize and apply topical steroids or give antihistamines by mouth.

If any of this doesn’t work, call me! It gets lonely in a pediatric office during the summer when all the kids are healthy.

Ten Tips from the Doc: Summer Vacation Success

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skateboarder-01School’s out! Time for the Family Vacation. So how do you have fun without going insane? I, of course, have my top ten!

10. Pack a simple medicine kit: don’t waste a day of vacation at the doctor’s office, refilling the prescription you forgot at home. Take:

  • any prescription meds your child sometimes needs, even if they haven’t used them in a while (asthma and allergy meds come to mind)
  • frequently used over-the-counter stuff: acetaminophen or ibuprofen, an antihistamine, insect repellant with DEET (the other stuff really doesn’t work, and insect borne encephalitis is unpleasant), sunscreen, and hand sanitizer
  • basic first aid supplies (band aids, gauze pads, tape, antibiotic ointment, cortisone cream, alcohol, tweezers, scissors, thermometer)

9.  Write out a budget before you go. I know, I am a fun sucker, but it has to be done. Know how much money you have and where you plan to spend it. Give the kids an allowance for souvenirs. They will be more careful with money they consider their own, and they will not be constantly asking for things. “Can I have that?” can be answered with “Sure, it’s your money. But are you positive that is where you want to spend it? There might be something better later…” Also, knowing how much you yourself have to spend will save you stress and regret later.

8.  Keep to healthy foods most of the time. (Here I go, sucking out the fun again!) Kids will have more energy, feel better and have a better attitude if they are nourished. And it’s cheaper. Have a basket of fruit available, some whole grain crackers, cheese, peanut butter, popcorn – food with nutrients. Don’t waste valuable vacation time sitting in the drive thru line and arguing over food.

7.  Keep to established routines when you can. Bring along a book for that bedtime story, keep bed time the same, set aside time for their bath. Kids don’t always deal well with change, and vacations are all about change. A few familiar routines will help them feel less stressed. And a full night’s sleep is an absolute necessity if you don’t want an emotional wreck for a kid.

6.  Keep an eye on the little ones. You are in a different environment with new dangers. Distractions abound. Kids on vacation get lost, or get into Grandma’s meds or the local pool. Check out my summer safety tips.

5.  Find interesting things to keep their brains busy. Bored kids whine, and then they find their own version of interesting things. Have a stock of books, games and videos for the car. Bring a journal for them to write in, and art supplies. Explore the area you travel to – Google it before you go. See the sights, hit the museums, find the local artists and craftsmen. Check out ideas to abolish summer boredom.

4.  Keep your own mind open to new and different ways of doing things, so that your kids will do the same. Kids internalize their parent’s judgments, and they will close down their minds and wipe possibilities out of their lives if that is the example you set.

3.  Keep them physically active as well. A tired kid is less stressed, sleeps better, and is not sitting around thinking of ways to get into trouble.

2.  Keep stress to a minimum. Use a GPS if you’re driving: arguments with the navigator have ruined many a vacation. Keep your expectations in line with the actual possibilities, to avoid disapointment. Don’t overschedule – leave time for that relaxing hike and to have a conversation over dinner. Stay within your budget – your hindbrain will know you are overspending and your stress will mount. Stressed out people snap at each other and cannot enjoy time or family.

1.  Align your vacation with your priorities, then toss out the rest. What are the goals of this vacation? Relaxation, family time, memories, enrichment, joy? Plan the vacation and activities that will get you there, and don’t let exhaustion, stress, and fear get in your way. Don’t stop at Uncle Joe’s house if you know he will stress you out; don’t vacation with those friends who overspend or forget to pay their half of the bill. Don’t worry if the kids are getting dirty or if your Aunt Judy wouldn’t approve. Just say no, open up, and relax.

And have a fantastic vacation!

That Tricky Line Between Safety and Smothering: Summer Injuries

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safety signSafety is not simple. There is no clear division between “this activity will be safe,” and “this activity will injure my child.” We could wrap our children up, keep them indoors, and not allow them to play with anything remotely dangerous, but then we would have a child who is lonely, overweight and really bored…who would get into trouble and injure himself. Or not get in trouble and develop diabetes, heart disease and knee problems from obesity.

Kids need to be active, and summertime brings many interesting opportunities for exercise, adventure and injury.

Wouldn’t it be great if some doctor type person would tell you what activities were the most likely to bring ER bills into your life?

Oh, wait. That’s me. So:

The most common causes of accidental death are gunshots, motorized vehicle and bike accidents, drowning, poisoning, and fire. Drowning, MVAs, bike accidents, and trampoline accidents are all more common in the summer, when kids are out of school.

Water Safety

Drowning is every pediatrician’s worst nightmare. It is currently the fifth leading cause of accidental death. An average of 700 children drown each year: about 2 each day. Most are under 4; 80% are male. For every death, there are 5 more children who drowned but survived, commonly with irreversible damage to their brains.

Infants and toddlers drown in bath tubs, buckets, toilets – it only requires is about an inch of water, just enough to cover their nose and mouth. Older children drown in pools, rivers, lakes, and oceans.

Never leave any child alone for even a moment near open water, whether it is an ocean, a bathtub, or a water bucket. All it takes is one moment of inattention for a child to slip away. If there is open water, you need to be within touching distance and focused on your child. The story I have heard over and over is, “We were right there, just talking, but nobody noticed anything until we realized he was gone.” Keep your kids in sight, and don’t let yourself get distracted. Be especially careful at the end of the day, as the water empties and people are gathering up their belongings and leaving. Children will want to swim just a minute more, or will attempt to go back for that last toy floating in the water.

Pools should be fenced in and closed off with a self-latching gate at the end of the day, and all the toys should be put away. Life vests are fabulous for a parent’s mental health and relaxation (swimmies and floaties are not life jackets). Life preservers and a shepherd’s crook should be placed obviously nearby wherever kids are swimming.

Sign your kids up for swimming lessons, even if you are afraid. A middle schooler or teen will never admit to their friends that they don’t know how to swim. They will fake it, sometimes unsuccessfully. Don’t, however, trust a young child to remember his or her swimming lessons when they need them. If they are startled or scared, they will forget everything they learned and just sink to the bottom.

Know what to look for. In real life, drowning does not look like it does in the movies. It is possible to miss someone drowning right in front of you if you do not know what you are seeing. They do not shout for help and wave their arms. They tire, and panic. A drowning child might never make a sound, but quietly slip under the water. An older child might keep themselves above the water for a while, but their head might be low in the water, with their mouth at water level, or perhaps with their head tilted back. Their eyes might be blank or closed. They will sometimes hang vertically in the water without paddling their legs, or appear to paddle with no purposeful movement. A drowning person is very easy to miss if you are not vigilant; and easy to help if you are.

Somebody should know CPR—why not you? Your local fire department or hospital will have classes.

Swimming is a necessary skill, fun, and excellent exercise; it is also a time for close observation and care.

Motorized Vehicles

The other motorized vehicles—ATVs, dirt bikes, snowmobiles, and Sea-Doos—are also commonly out in the summer. They are the perfect storm: they go fast, have no outside framework, roll over easily, and the only things that keep them from crashing are your children’s foresight, common sense, and trained reflexes. The United States averaged 23,800 dirt bike crashes requiring emergency room visits every year between 2001 and 2004; these numbers go up as dirt bikes become more popular. Don’t. Really, just don’t. You do like the kid, right?

Bikes

Bikes come out of the garage when the weather warms up and the roads are not covered in ice. And yes, the dorky bike helmet is an excellent idea.

Thousands of children are injured or killed every year due to bike accidents, frequently right near their homes. In 2010 alone, there were 800 deaths, 26,000 traumatic brain injuries and 515,000 emergency room visits after bike accidents.

Asphalt is not soft, even right next to your house. When a car hits a child, the child flies through the air. The heaviest part of the child—the head—lands first.

Make them wear the dorky helmet, on top of the head please, covering the top of the forehead, and tied snugly under the chin, not dangling on the back of the head. Hang it on the bike handlebars when not in use so that it is the first thing on and the last thing off. Keep a big lock handy so that if you catch them on the bike without the helmet, you can lock it up and they can walk for a week. Sorry kid, that was the rule and you knew it. There is no need for any argument.

Please don’t buy a bike two sizes too big. Your child will fall off. Children should be able to place the balls of their feet on the ground while their rump is on the seat, and their whole foot should be flat when they are standing over the crossbar. An extra bike or two over the years is cheaper than a broken child.

Trampolines

Trampolines are a huge source of income for surgeons and orthopedists. If you would like to make them poor, don’t buy a trampoline. If you have one, please be careful. Most trampoline accidents occur when there is more than one person on the trampoline, especially when they are not the same size. The smaller one goes flying or is fallen upon. Safety nets and pads are better than no safety nets and pads.

On second thought, forget I said all that. Let’s go back to no trampolines. Kids break bones, damage their kidneys, and hurt their heads and spines.

Children will at some point injure themselves because they need to be free to run, swim, and climb monkey bars and trees. Try not to obsess over scraped knees, a goose egg on the forehead, or a few stitches. Everybody gets those, and your children will find a way. Concentrate on the risks that will kill them or seriously injure them: motor vehicle accidents, drowning, fires, poisonings, and gunshots. Don’t go out of your way to buy things that will hurt them, such as trampolines and ATVs. Make it so they have to get creative if they want to injure themselves. Creativity is good, right?

My Rant: It is not Malpractice to be Tired

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kidsfightingFair warning: I am on a rant. Skip this one is you don’t want to hear me whine.

In the last few days I have seen doctors in the media picked on because they fell asleep (“Doc, there are patients who need to be seen!”), because they were burnt out, and because they didn’t smile, explain things thoroughly, and ask about the patient’s home life while checking for an ear infection. Doctors fought back with comments about their long hours, intense work schedules, and exhaustion.

It didn’t work. The comments just changed to: “Well, fight for better hours!” Or: “Be willing to make less money!” (umm, I did go into pediatrics…) One person was actually so narrow minded and idiotic as to tell us we were harming patients by working too hard, and that it was sheer laziness that kept us from improving our schedules. That we “were keeping our heads buried in the sand” so that we did not see the important issue: that the business of medicine was as important as the practice of medicine. That what we were doing was “not good enough,” and that doctors never fight for anything. How that person knitted all those ideas together in one head is beyond me, and I don’t believe that I, or any other doctor, deserved it.

First, no one was harmed in any of the situations. The sleeping doc got up and went back to work, probably better for the quick power nap. The child whose doc did not smile and ask about their home life nevertheless fit that child into her already full schedule and took excellent care of her. I have in thirty years never harmed a child because I was exhausted. I did once tell a mother that I was too tired to care for her child and would find them another doc, after which I walked back to the office, sat down, passed out and had a seizure. Doctoring is a different sort of job.

Second, doctors have been fighting far longer than I have been one. We fight with insurance companies every day. Through the AAP we fight in the legislature for pediatric issues. We fight for universal vaccination. We fight for neglected kids, for abused kids, for healthy foods in schools…

Last, our heads are about as far out of the sand as they can get, as we care for children whose parents have poured boiling water over them, for teenage girls gang raped at parties, for gay children who are thinking of slashing their wrists…

There are a limited number of hours in the day, and every single time the kids matter more than how overworked we are.

The one thing that I am never willing to compromise is the care of my patients. Jumping from “doctors are overworked and stressed” to “doctors are harming patients because they are overworked and stressed” is a leap. The data actually proves otherwise.

Presuming we can simply work less and everything will be fine is naïve.

One of the biggest problems right now is that there are simply not enough docs, and fewer of them are going into and staying in primary care. Those of us in the trenches cannot do less when there is no one to take up the slack. Legislation can not fix this problem, and the fact that we are judged and condemned at every turn just puts another nail in the coffin of primary care. The doc above fit an extra patient into her day, took care of the acute problem, and was spat upon because she didn’t smile and answer questions that weren’t even asked. If burnout is a concern, then stringing us up for target practice just because we are doing our jobs is a problem.

So here is my fight for the day, because I do not want to be accused again of not fighting enough: please appreciate the 11 or more years we spent in school and worked for free, accumulating debt while you were already earning a paycheck. Please appreciate the fact that when you call at 2AM, we answer. Please appreciate the times we miss important events in our children’s lives because we are helping someone else’s child. Please appreciate the fact that we carry the responsibility inherent in our jobs on our backs every minute of every day.

A simple “Thank-you for fitting my child into your busy day,” will go much further toward keeping doctors in primary care than any change in our work hours or income. We are not the enemy; we became doctors because we wanted to help people. Please let us do our jobs, and don’t snipe at us because we are tired. The fact that we are tired and overworked is not a good enough reason to fault us. We do not deserve it, and we have earned at least that much respect.

Whether or not the insurance company pays that $35.00 is always going to be at the bottom of my priority list, as it should be. The business of medicine will never and can never be as important as helping that little boy in room 2 to breath better.

Your Daughter’s Vagina

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marilynThis week my amazing daughter handed my son-in-law a daughter. This brand new person has lots of silky dark hair, deep blue eyes and 2 dimples. She is a 7# 8oz miracle.

In the last few days my son-in-law has heard endless versions of “You’re in deep trouble, man,” “You’ll need a shotgun,” and “The boys will be after her!” My son-in-law is a deep thinker, so he gave it some deep thought and said, “Why?”

Assuming we want our daughters to have joy in life, fulfillment in their chosen work, family, and love: why then do we not want them to have sex? It seems an essential part of the picture.

When we actually consider why we feel this way, it comes down to the unfortunate fact that we equate a woman’s value with her sexual appeal, but devalue women when they actually have sex. No sex? Virginity and a pedestal. Sex with one man? Mother and Madonna. Sex with more? We have a direct line of descent into whoredom, where your daughter can be given a monetary value.

Then we confuse this scale by judging a woman’s value by how sexy she is. I once heard a med student say about the best kid cancer doc I knew, “What else could she do? She’s damned homely.” We want our daughters to be sexy, but not to have sex.

The valuation for men is perhaps equally harsh, but diametrically opposed. Virginity brings snickers and derision. Faithfulness to one women is sometimes thought to be gullible and foolish. Sex with many women is part of the admirable macho stereotype: men have conquests and “sew their wild oats,” admire James Bond, Casanova and Don Juan, and slap each other on the back as they carve notches into their belts or acquire trophy wives.

Math works, and these numbers do not add up.

There are of course other problems with these assumptions: not only are we devaluing our daughters, we are also making life difficult for our sons. We want our boys to have self respect, good long term relationships with their partners and the maturity to hang around to see their children grow up. Herpes, AIDs, and serial shallow relationships devoid of respect will not bring them this future.

So what is the solution?

We need to give our own values serious consideration, and then evenhandedly teach those values to both our sons and our daughters. We cannot tell our boys that it is OK to get a girl drunk so that she will have sex with them, and then tell our daughters that if they drink too much and have sex they are whores. We cannot tell our boys they are not manly if they choose to wait for love, and our girls that they must wait, or they are trash. It does not work to dress our seven year old daughters in spangles and teach them to hip thrust to sexy music, but then insist they remain innocent.

We need a coherent, honorable, human plan. Consider the future you want for your child, give thought to how sex fits into that future, be fair, be stringently honest, and build rules consistent with that future.

Some simple rules might be: we don’t want you to have sex until you are fully mature; we want you to be in a relationship built on love and mutual respect when you do; we want you to be safe and responsible.

Follow your own rules. Start when your babies are brand new, behave honorably, and be consistent throughout their childhoods. “Do as I say, not as I do” has never and will never work, because in the end your children will know you very well indeed.

  • Watch what you say, both to your own partner and about the other people in your life, because words and judgments will worm their way into your child’s mind and later poke holes in his or her self worth.
  • Keep conversation open, so that when they hear something at school or at a friend’s house they know they can ask you about it. They need to be able to come to you when they have questions. Give them knowledge so that they will be able to make good decisions.
  • Monitor what they see on the internet and on TV. Much of what is on screens these days will need explanation.
  • They will probably make mistakes. When they do, it is perfectly all right to discipline them, because they did break your rules (aren’t you glad you made those rules beforehand, and made sure he or she understood them?) Do not, however, add judgment to the mix. Give them time and space to think and consider the consequences of their actions. Allow them the chance to do better next time. Everyone makes mistakes, and it is hard enough to forgive yourself and go on, without the ones you love adding to the weight of regret in your heart.
  • Never throw labels at them, because labels will leach onto their brains forever. They will never forget that their parent, who should love them no matter what, called them trash, or a slut. They might even feel that they have to live up to the label.
  • Sex is a powerful weapon. If handled well it can bring joy, deepen a loving relationship, and create life. A parent’s example provides the model, good or bad, for their child to follow; thoughtless words from that same parent’s mouth can echo in their brains and make them bleed.
  • Society’s views, as seen in your neighborhood or church, and on the screen in everything from commercials to movies to music, have an impact.
  • How we think about sex, our behavior, and the inner judgments of our own actions effect everything from our relationships to our health, our self esteem to our future.

Sex can be a natural part of a fulfilled life, or it can injure your child’s mind, body and soul, up to the point of self-injury, depression, and death. It is important. It is deserving of respect and careful consideration, and an absolutely equal and consistent application of those conclusions to the parenting of both our sons and our daughters.

My son-in-law is brilliant, you know, and he was right.