obesity weighs heavily on my mind

I was reading the NY Times online today, catching up on news of the world around me. In the past 10 days or so, there has been a series of articles about doctors counseling patients about weight loss (http://tinyurl.com/63d9zh). I was definitely intrigued by the headlines, as I was recently told that I was mean to my overweight patients; I am honest with my patients. What was more interesting to me than the articles themselves were the comments. The basic idea is that overweight and obese people know they are overweight and don't need another lecture. I can see that, although in my office it tends to be the parents who already know their children are overweight, and are often overweight themselves. But I still feel that it is important to show the child (depending on the child) and the parent(s) the growth chart with the BMI plotted. Maybe in doing so, I am being too harsh. Yet, I feel that if my concern is health, I need to address the topic in a frank way. I do ask families how I can help, and I try to refer them to a nutritionist, if available; when necessary, I check a lipid profile. I can think of other things I would like to do, like change school lunch menus, get kids in daily physical education classes from kindergarten through 12th grade, and teach parents how to cook in a healthful way, but we don't have the resources. I do as much as I can to offer solutions, like cutting out the ramen noodles and flaming hot cheetos! But I also ask parents not to keep unhealthy snacks in the house. Just the other day, I had a parent tell me that it makes her 107 pound five year old son sad when she goes to the grocery store and doesn't come home with ramen noodles, and I suggested that that was OK that he was sad, that she could perhaps just make them as a treat once in a while. My patients know though that I am their loudest cheerleader when they start exercising and watching what they eat, even if they don't lose weight right away.

Immunization Alliance

Yesterday, I posted about the AAP's current focus on parent education on immunizations, since it was voted the No. 1 resolution at the ALF in March. Today, I opened my AAPNews for July, and what's on the first page? A great story about the development of the Immunization Alliance. For those of you who haven't seen the article or who don't receive the magazine, I'll sum it up. This is a working group of fifteen members, including people from the AAP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Medical Association, the American Public Health Association, the Association of State and Territorial Health Officials, Easter Seals, Every Child by Two, the Immunization Coalition, the March of Dimes Foundation, the National Foundation for Infectious Diseases, the National Vaccine Program, Parents of Kids with Infectious Diseases, Rotary International, and Voices for Vaccines. They hope to come up with an effective media campaign that addresses parent fears and increases confidence in vaccines. This team is aware that the campaign needs to address a parent population that is comfortable using the Internet as an important source of information and that time is of the essence. I now that I, for one, will be eagerly awaiting their media campaign, especially now that Guardasil is in the news too!

Pediatricians and guns

I was listening to NPR the other morning as I was getting ready for work, and I heard about the Supreme Court decision regarding Washington DC's gun restrictions. I immediately started thinking about the AAP reaction to this news, and sure enough, there was already an email news alert waiting for me in my inbox when I got to work.

I live in an area where many, if not most, people have guns at home; in fact, I suspect my entire AAP district, district VIII, has a fairly high gun ownership rate, as it includes Wyoming, Montana, Alaska, Washington, Oregon, Idaho, Utah, Nevada, Colorado, Arizona, New Mexico, and Hawaii (although I honestly know little about gun ownership there). Some of my patients hunt regularly with their parents, and other families keep guns for protection. I address the topic daily, using any teachable moment I can to ascertain which families are aware of gun safety, and which are not. I cringe when I hear about the loaded gun under the pillow. Any gun in the home is a potential weapon, a tool for suicide, altogether a danger.

During medical school and residency, I took care of several children who were the victims of accidental shootings. One teenager in particular comes to mind. He and his brother, who were well-versed in gun safety and had various guns of their own, decided to clean their dad's shotgun as a surprise to him. Unfortunately, there was a shell in the chamber, and in the process of cleaning, the one brother accidentally shot his brother's eye out, nearly killing him in the process. Their parents were horrified at the carelessness of the one boy because they had taught them about gun safety, but they were home alone, unsupervised.

This was a tragic accident. I feel strongly that, even with "trained" children at home, guns should be kept in a safe that only the adults have access to. In other words, we should try to eliminate access to guns in unsupervised situations, although I am aware that accidents also happen when an adult is present. I also believe that there are types of guns that should not be sold to private citizens. However, what irks me about this whole issue is that children are exposed to many dangers all the time, and we don't have that knee jerk reaction that we have with guns. We've all had parents tell us that they would never have a gun in the home because it's not safe, yet they smoke in the home and allow their children to get out of their carseat because "they just won't stay in;" these are all potentially detrimental to the health of their child, and I try to make that point with the families.

I suppose that my point is that we, as adults, need to protect our children by putting them in car seats, by locking up guns, by feeding them healthful foods, by locking up the bleach, by immunizing them, etc. I know nobody disagrees on this point, I just wish that we would put as much effort into some of the less obvious dangers that they face as well!

ADHD

Oh how these four little letters can stir up so much debate!! Speaking of debate, I won't address politics anymore; it made me feel too weird. Next time I am lacking ideas, I'll simply talk about the weather or nail polish colors.

So, do you think this kid in the cartoon was actually listening to Dad reading the story, or thinking about the DVD he watched, the new video game he learned, etc.? But he clearly has a skill, even if it's one his parent doesn't have!

As a pediatrician, I get lots of questions from families, friends, and patients about ADHD. Having worked in early intervention in the 90s when the diagnosis was becoming quite fashionable, I had a non-medical perspective, one that was more influenced by families and preschool/daycare teachers. From this view point, I saw children who were quite intelligent, but parents and teachers had a hard time working with them due their distractability and/or inattention. These children were often in classrooms with many children, some typically-developing, some with special needs. The challenge in the classroom was huge. As an early interventionist, I would try to work with the teachers and the child in the classroom to help them learn to work together. Often, I would request that a child be put in a smaller class or a different center all together. However, this was not always an option.

Then, I went to medical school. In my pharmacy class, I learned how the different stimulants affect the brain and the body; I obediently learned the different dosing schedules, half-lives, metabolites, etc. I was exposed to pediatricians who felt that the diagnosis was a farce, an excuse for poor parenting and teaching, as well as pediatricians who were committed to the diagnosis. During residency, I worked with one pediatrician who felt that pharmacotherapy was most indicated when a child's self-esteem was affected by the ADHD - this has really stuck with me, and I continue to use it as a guideline in my practice.

Now I am a pediatrician, simply with a background in early intervention and special education. I was also diagnosed with ADHD during medical school, in case you hadn't guessed already! I love taking care of these patients who tend to be quite imaginative and often questioning of authority; it is incredibly rewarding, yet quite frustrating at times. I spend a lot of time discussing non-pharmacologic ways of dealing with ADHD, including regular exercise, good sleep hygiene, healthful diet, and strength-based learning, as illustrated by the cartoon at the top of this blog. However, as we all know, these strategies don't always work; parents do not always have the option of putting their child in a private/charter/alternative school, and homeschooling can be difficult as often the parents have ADHD themselves. And incredible results can be obtained sometimes with the right medication, in conjunction with everything else. Ultimately, my goal is to teach kids how to cope with school and ideally to excel in school, how to live with rules, and how to navigate in a tremendously busy world with many distractions. Unfortunately, I know that some will try self-medicating, some will struggle with depression, but I remind myself that with help, many can be successful, bright, innovative leaders.

There are lots and lots of resources out there for ADHD, but here is a website that I find is a good place to start: http://www.help4adhd.org/index.cfm?varLang=en.