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The heartbreak of really letting go

Posted by Dr. Claire McCarthy August 29, 2012 08:10 AM
Thumbnail image for zack at airport.jpgI am a bit of a mess this morning.

I just put my son on a plane to China. Well, I put him on a plane to Newark, but from there he is headed to Beijing for a semester. 

I am trying really hard not to cry.

It's not so much about missing him. I mean, I'll miss him (I already do), but I'm used to missing Zack. We haven't seen much of him since he left for college a couple of years ago. He has done service projects on spring breaks, and spent this summer doing an internship in DC. And truth be told, he has a way of getting on our nerves when he's around for more than a few days (this is common with 20-year-olds), so we've been mostly okay with him being away.

But not this far away.

That's the thing. He is going to be half a world away. I can't get to him quickly if there is a problem. I don't speak the language of the place where he'll be. I don't know the culture. I don't know anybody there. I know, he can call or email me, but I am going to be really limited in what I can do to help.

I can't take care of him there. He really has to take care of himself.

It's not that I don't think he's capable. Zack is a very capable young man. He's bright, independent and resourceful. He doesn't need my help all that often...but being able to help has been important to me.

I love him more than I will ever be able to tell him or show him. He is unspeakably precious to me, and I would give my life for him in a heartbeat. That his well-being and safety is up to him and to others I don't know is heartbreaking.

It's so hard. From the first time you hold your child in your arms, they become part of you in inexplicable, wonderful and sometimes painful ways; you are never the same. And when they leave, they take part of your heart with them.




Circumcision update: benefits outweigh risks (but it's still a personal decision)

Posted by Dr. Claire McCarthy August 27, 2012 06:21 AM
A few months ago, I wrote a blog about circumcision. In it, I said that the American Academy of Pediatrics (AAP) was "firmly on the fence" when it came to the procedure, saying that the risks and benefits were about equal.

That just changed.

It's really a change back, because when I started practicing as a pediatrician, the AAP was in favor of circumcision because it decreased the risk of urinary tract infection and penile cancer. Then in 1999 they changed their stance to a more neutral one, and said that families should make their own decision based on their personal and religious beliefs.

Since then, it's become really clear that circumcision makes a difference when it comes to preventing sexually transmitted infections. The thin inner surface of the foreskin is easily injured, allowing germs in, and the foreskin itself may "trap" germs underneath. Not only that, there are cells in the foreskin that are targets for HIV infection. HIV rates are definitely lower in circumcised men--as are rates of genital herpes and Human Papilloma Virus (HPV) infection, which is the main cause of cervical cancer.

That's what's a bit different for me about this new policy statement: they aren't just talking about the health of men. They are talking about the health of women, and how if more men were circumcised, there would be less HIV, genital herpes, HPV (and subsequent cervical cancer) and other sexually transmitted infections for them, too.

There are still the same benefits in terms of lessening the risk of urinary tract infection (mainly in infants), penile cancer (although that risk is small), and problems with the foreskin itself such as infections or getting stuck (obviously if you don't have a foreskin you're not going to have problems with it). And after looking at lots of studies, the AAP said that there is no good evidence that circumcision interferes with sexual pleasure or function.

The biggest objection to circumcision is generally that it is painful--and this is an important concern, especially since it's usually done on newborns (there are fewer complications if you do it then than if you wait). The technical report that went along with the policy statement statement took this very seriously, saying that pain should absolutely be prevented using medication (sugar water isn't enough). The report also stressed that it's important that the procedure be done carefully and by someone who is skilled and experienced at doing them.

The AAP stopped short of recommending circumcision, though. While the benefits are greater than the risks, they say that the "health benefits are not great enough to recommend routine circumcision of all male newborns". As I wrote in my previous blog, circumcision is yet another example of how often medicine offers information, not answers. What the AAP did this week is give a bunch more information. What parents do with that information is, as it's always been, up to them. 




The four habits that can keep your child at a healthy weight

Posted by Dr. Claire McCarthy August 23, 2012 08:58 AM
These days, we hear a lot about childhood obesity. Which isn't surprising, given that a third of US kids are overweight or obese. The implications for their future health--and our health as a country--are staggering; this is the first generation that may die before their parents do.

We also hear a lot about what we should do about it. Sometimes the advice can be overwhelming, or seem impossible. When I tell some parents that their kids should be eating five servings of fruits and vegetables a day, they look at me like I have five heads--there's no way their fruit-and-vegetable-hating kids are going to do that. I get the same looks sometimes when I talk about sports teams or whole grains.

Lives are complicated, I get that. And kids don't always do what we want them to do. If we are going to make real changes, they need to be changes we know will work. We need them to be "evidence-based", which is our fancy medical way of saying proven by good medical studies.

So here are four habits that medical studies have proven to work when it comes to preventing and treating childhood obesity. And what's even better, they are all straightforward and relatively simple.

1. Make sure your child gets ten hours of sleep a night. When kids get less, it causes stress on the body and can slow the metabolism, making weight gain more likely. So get your child into good sleep habits. To help them get the full ten hours, start the calming bedtime ritual a good hour before that, and get the TV out of the bedroom. And speaking of TV's...

2. Limit screen time to less than two hours a day. I know this can be hard (getting the TV out of the bedroom helps), but studies really do show that kids who spend than two hours in front of a screen (TV, computer, video games) each day are more likely to be overweight.

3. Get your child active for at least one hour every day. A sports practice is an easy way to package it, but active play is great too--stop at the park after school, pick child care that involves activity, make activity part of your weekend plans. Go for walks as a family--you'll be setting a good example and having some nice together time.

4. Don't give your children any sugar-sweetened beverages. None. Zero. Zilch. Well, I suppose once in a blue moon, like at a special restaurant outing, is okay. But don't have any soda or sugared juices in the house. They are calories your kid just doesn't need (actually, nobody in your house needs them).

I'm not saying that fruits and vegetables and whole grains aren't important, because they are. Check out the low glycemic index diet, as a recent study showed it was best for weight control. And it would be really great if more kids could play sports. But we have to start somewhere, and we should start with the proven basics.

For information on where you and your family can exercise in the Boston area, and for great recipes and other healthy ideas, visit the Healthy Family Fun website of Boston Children's Hospital.

How to discipline toddlers

Posted by Dr. Claire McCarthy August 20, 2012 06:58 AM
I love toddlers. They are little forces of nature, full of energy and curiosity. But that energy and curiosity can have downsides, too, as any parent of a toddler can tell you.

There is a common misperception that toddlers are too young to discipline. It's true that they are  young and don't understand everything you'd like them to understand. Their short attention span doesn't help, either. But you absolutely can discipline them--and you should, because it is crucial to getting them on the right road to good (and safe) behavior as they get older.

When my eldest was a toddler, our pediatrician gave us three rules for disciplining toddlers that I really like:

1. Set limits.
Toddlers understand the word no (this is the age they start saying it to you!) and it's important to use it with them when they do things they shouldn't. It may be cute when they hit or bite, for example (especially since they are too little to do much damage), but it's a lot less cute when they get to be three or four--and it's a lot tougher to get them to stop if you start then. 

Make sure you have their attention when you deliver that firm, stern "No." Say it immediately after the action (or they'll forget what they did), and make it really clear what the transgression was--like by holding the hand and saying, "No hitting." You can use Time-Out, too: put the child in a boring place for a minute or so (rule of thumb for Time-Out: one minute for each year of age). If they get up and get out, bring them back--but don't interact more than that, as the point of Time-Out is to take away attention, not give more of it.

2. Be consistent.
This is really hard, especially when you are tired--and what parent of a toddler isn't tired? But if they can get away with things sometimes, they will keep doing them. No has to really mean no--all the time. It's also really important that all caregivers are on the same page--if you are consistent but Grandma isn't, it's going confuse your toddler (and present an opportunity). 

Being realistic, the only way to ensure consistency is to...

3. Pick your battles. 
With a toddler, you could spend your entire day saying no. Which is no fun for anyone. So pick your battles. If they do something that could hurt them or someone else, that's a definite no. But maybe you can live with some of the other stuff...like making messes, or being loud (in a place where loud is okay). You also need to work with what's possible for this age--you may really want to go to that restaurant or movie, but your toddler likely just can't stay still for that long. It's not fair to punish them for, well, being a toddler. 

After all, they are forces of nature.

Three ways to make your child healthier this school year

Posted by Dr. Claire McCarthy August 16, 2012 08:10 AM
It's back-to-school time, which means lots of getting ready. It's a time of year that is full of shopping--and planning. Life changes so much from the end of summer to school time; so many routines and activities change. 

That's why it's the perfect time to add some plans--and changes--that can make your child healthier. With all the plans and changes you're making anyway, you're much less likely to meet resistance than if you try it later in the year.

Here's what I suggest:

Plan for your child to be active. Have your child pick a sport--maybe plan on having them play one each season (fall, winter, spring). Or sign them up for a dance class (my son's best friend and his brothers do hip-hop) or skating or swimming lessons. Maybe decide to walk or bike to school a few days a week. If you talk about it together and ahead of time, kids are more likely to be enthusiastic about it.

Plan healthy meals and snacks. We all start out with the best of intentions--but then we get busy, and buying lunch at school or packing that bag of chips ends up being what works for our life. This year, get some cookbooks and plan healthy packable lunches and snacks. Try them out this month, see which everyone likes best and figure out the best way to pack them so they stay fresh and appealing (experiment with making them the night before, or a few days ahead, for time-saving options). The Healthy Family Fun website of Boston Children's Hospital has some great recipes you should check out. Then when the school year starts, you'll be ready to go.

Plan a schedule that gives your child ten hours of sleep every night--and some downtime. So even though I said to sign them up for sports or other activities, don't overdo it. Make sure there is some unscheduled time for them to relax--it's important for their mental health (and yours--running kids around all day is stressful!). Talk together about when (and where) they will do homework--don't let it wait until they are tired or out of time. Decide on a bedtime, and stick to it.

While you're at it, make some plans for family time. Childhood goes by so quickly; before you know it they will be grown and gone. So plan some family outings, or even just movie nights and game nights. Make it part of the routine. You'll be glad you did. 


Got a kid who hates taking medicine? What to do.

Posted by Dr. Claire McCarthy August 13, 2012 06:59 AM
My middle daughter, Elsa, hated taking medicine when she was little. She would fight me tooth and nail--and often once I actually managed to get medicine into her, she'd glare at me and vomit it back up, usually all over me.

As hard as it was, it taught me a lot about do's and don'ts when it comes to giving meds to kids who really don't want them. My patients and their parents have taught me a lot, too. In an attempt to save you some trouble (and from being covered with medicine-filled vomit) here's a summary of what I've learned from Elsa and others:

Only give medicines if really necessary. This sounds obvious, but often parents do give medicines that aren't completely necessary. Like acetaminophen for a low-grade fever. Or cold medicines (they don't really work and can be dangerous). Talk to your doctor about which medicines your child really needs and which are optional. This will help you when you...

Take charge of the situation. Make it clear to your child that taking the medicine is non-negotiable. Kids are smart; if they sense any wiggle room, they will refuse even more. You don't have to be all fire and brimstone, though; it's totally okay to...

Use incentives. We all are more likely to do things if they are worth our while. "If you take your medicine quickly, we will have time for an extra story." Or "I know you don't like your medicine. How about we have a little ice cream after to make the taste go away?"

Use the proper implement for liquid medicines. Don't use a spoon--too much chance for spillage (and, unless you use a measuring spoon, too much chance of giving the wrong amount). My personal preference is a medication syringe (most pharmacies carry them). If you have a preschooler or older who freaks a bit at getting stuff squirted in his mouth and will cooperate, use the medication spoons that have a cylinder for measuring as a handle (also available in pharmacies)--it allows you to pour out a little at a time.

When squirting into a mouth, remember:
  • Aim back (but not too far back) and to the side. If you go too close to the front it's easier to spit out, but if you go straight back the child may gag.
  • Don't squirt all at once. As tempting as it is to get it over with, if you don't want to be wearing it, wait until they swallow each bit before giving more.
  • If you've got a squirmer: hold your child so that they are leaning back. Put the arm closest to you behind your back, and hold the other one down with the hand of the arm that's cradling them. If you've got a kicker, you can put their legs between yours.
A chaser may help. Something strongly sweet is often effective--I've had good luck with chocolate syrup. Honey is good too--but never use in a baby less than a year old, because of the risk of botulism. With really nasty-tasting ones, I've sometimes filled a syringe with chocolate syrup and alternated medicine with chocolate. Eating some crackers can help kill the taste too, or brushing teeth (which is good to do after giving iron or iron-containing vitamins).

Use the smallest volume possible. Your doctor will likely need to help you with this one--whenever they prescribe something, ask if there's a way to do it in less volume. For example, 250 mg of Amoxicillin would be 5 mL of the 250 mg per 5 mL formulation--but just a smidge over 3 mL of the 400 mg per 5 mL one. Which can be a big difference with some kids.

Consider flavorings. Some pharmacies will do this. However, it's not always possible and it doesn't always help...so it's something I recommend only when all else fails.

Consider chewables, or crushing a tablet. You'll need your doctor's help on this one, too. The chewables don't always taste wonderful, but some kids just take them better. And a crushed tablet mixed with a little bit of something soft and sweet (like pudding) may be an easier sell than a big syringe of liquid (my personal preference is to mix crushed tablets with food, not liquids--they often settle to the bottom of liquid or get stuck to the sides of the cup or bottle).

My last piece of advice isn't so much advice as a plea...

Tell your doctor if you can't get your child to take the medicine. I can't tell you how many times parents have just given up and not told me, even on important medications like antibiotics. Sometimes stopping a medicine can be dangerous. And there's often an alternative--either a different formulation of the same medication, or a different medication, or a whole other treatment entirely.

After all, medicine works best when parents and doctors think creatively--and work as a team.

 

Another inconvenient truth: what kids see on TV affects them

Posted by Dr. Claire McCarthy August 5, 2012 03:03 PM
My 6-year-old, Liam, has watched all sorts of things on TV I wish he hadn't.

Liam is the youngest of our children; the others are 21, 19, 15 and 11. All of them like to watch TV. They come by this honestly; my husband loves to channel surf. It's how he relaxes. Whether it's nature or nurture, my kids take after him.

We have rules and limits, of course, and mostly they land on good stuff when they surf (well, not my eldest, who tends to land on things like the Kardashians). But sometimes they land on a violent documentary or Lord or the Rings battle scene or something else their little brother shouldn't watch. And every once in a while, Liam wanders in and watches.

This week, a study came out showing that when parents of preschoolers were encouraged to have their children watch educational shows meant for preschoolers (like Sesame Street or Dora the Explorer), the preschoolers slept better. Watching shows that are violent or not meant for preschoolers, it turns out, has a way of interfering with sleep.

This makes sense (and I don't think the shows put them to sleep, although Dora could do that to me). Children are affected by what they watch, especially young children whose brains and world views are still very much developing. 

That's what worries me, as a parent and a pediatrician. When young kids don't sleep well, we know that it can cause behavior and school problems that may not show up until later. A study by the same researcher last year showed that when kids watch fast-paced cartoons it can mess up their executive function, skills that are crucial for academic and social success (and success in life overall). Being exposed to a lot of violence in the media, in shows or movies or video games, can lead to more aggressive behavior--and kids who are exposed to more sex in the media may be more likely to start having sex early. The decisions we make now about what our kids see can affect the rest of their lives.

Yikes.

We need to pay attention to these studies. More and more, media is part of life. It's not all bad--in fact, there are ways in which it's great. But we need to be thoughtful and careful when it comes to our children and what they see.

There needs to be some plain old-fashioned censorship, at least when kids are really young. There is some stuff that kids just can't handle--anything really violent or frightening or sexual, for example. In our house, that stuff is only supposed to be watched (if at all) in the den where the door can be closed tight, or after the younger kids go to bed. Mostly, that works.

But sometimes it doesn't. And sometimes shows have a way of being unexpectedly violent or sexual (like the Glee episode that our 11-year-old watched while my husband was giving Liam a bath, that turned out to be entirely about sex, leading to some rushed birds-and-bees discussions)--and you never really know how any child will react to anything. That's why we need to talk with our children about what they see (we've done a lot of that with Liam). Even better, we need to watch things with them so we can gauge their reactions, process with them--or just shut it off.

This isn't easy, with busy lives and a media landscape that is rapidly growing and changing. Two great websites that can help are Common Sense Media and the Center on Media and Child Health--they have lots of practical advice for parents.

So far, Liam is a good sleeper--and I guess time will tell whether those not-so-kid-friendly things he watched affected him in a way we'll regret. As with everything in parenthood, all we can ever do is keep trying to do better--and hope for the best.






Got a kid with asthma? The four things you need to do this month.

Posted by Dr. Claire McCarthy August 1, 2012 02:13 PM

In the primary care practice at Boston Children's Hospital where I work, we've noticed that in September a lot of our patients with asthma get sick enough to need to be hospitalized.

We're not entirely sure why this is, but we have some ideas. Fall allergy season is definitely part of it, but we don't see the same spike in the spring, so that's not all of it. We think that some of it has to do with people getting a bit, well, relaxed over the summer--and getting caught off guard when new routines and new demands--and new asthma triggers--arrive in September.

If you have a child with asthma, here are the four things you should do this month to give them the best chance of a wheeze-free fall:

1. Make sure you have an Asthma Action Plan. These are written plans that list all the medications your child needs and when and how they should be taken. They are usually divided up into three "zones": green for when all is great, yellow for when asthma is acting up, and red for when it's really bad. Because the instructions may be different depending on which zone your child is in (and because many children with asthma need several medications), it can get confusing--having it written down makes a big difference.

2. Check all your medications to be sure you have enough. There's nothing worse than having a wheezing kid in the middle of the night and reaching for medicine--only to find that it's all gone. Many inhalers have counters on them to let you how many puffs are left. If you're not sure, bring it to the pharmacy for help. If you need refills, call your doctor's office. If you need extra to leave at school, be sure to ask for that too.

3. Get the paperwork you need for your child to get medication at school. Without an authorization from a doctor, the school nurse might not be able to give anything if your child is wheezing--and things can get worse in the time it takes you to go get them. If you can't get the exact forms from the school, your doctor's office should be able to provide you with something you can use.

4. As soon as it's available, get a flu shot. Usually the flu shot becomes available around the end of August. People in high-risk groups, like kids with asthma, should be among the first to get it. Stay in touch with your doctor about when it will arrive, and keep an ear out for flu clinics in your community. Remember that everyone in the family should be immunized if you want to be sure to keep your child safe. For more information about flu vaccine, visit www.flu.gov.

Get all this done now (you can do it all in a visit to the doctor--we try to get as many of our asthma patients in as we can) so that you can give your child the best, healthiest school year possible.


If your child has an inhaler, they should be using an aerochamber. Here's a video on how to use one (for more videos, check out the bottom of our Asthma page):



About MD Mama

Claire McCarthy, M.D., is a pediatrician and Medical Communications Editor at Boston Children's Hospital . An assistant professor of pediatrics at Harvard Medical School and a senior editor for Harvard More »

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