Archive for June 2013

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The Value of Play

bike ride 2013

As we transition to summertime we get to focus even more intently on play. Not as easy as it sounds.

There’s a balance with having a routine and structure for your child while also facilitating some time for creative play. Unstructured play doesn’t get the voice it deserves in my opinion. Parents ask me about the camps I’ve signed up for far more than they ask what downtime my children will get this summer. In my mind, the perfect summer is a blend of scattered exciting opportunities with swaths of time ready for unstructured play.

Boredom can be good for heavily scheduled children and can foster creativity

There’s lots of stress amidst the celebrations and change that comes with the end of the school year. Children thrive in routine, so even a good transition out of school can cause disruption. Some children will have insomnia, decreased eating, or even feelings of anxiety. Big changes can trigger feelings of depression in some children, too. Check in with your child if you’re worried and remember that more important than what you say will likely be that you listen.


Maria Montessori famously identified the value of play saying, “Play is the work of the child.” Play is so important it is a protected child human right by the United Nations. Just as labor laws protect our children from hard labor and work, we parents must protect their chance to wander, dream, roam, and discover. Research shows play is important for brain development, an important platform to learn decision-making, and offers up a tool for children to identify their passions. I don’t mean time in front of the TV or DS. I mean time outside, in the backyard, or in a child’s room. In the 2007 American Academy of Pediatrics statement on play, Dr Ken Ginsburg wrote, “In contrast to passive entertainment, play builds active, healthy bodies.” Read full post »

Why You Should Make Sure The Helmet Fits

Buying the bike helmet isn’t enough, of course. We have to make sure our children actually wear them. We’ve gone through phases at our house (loathing to loving the helmet). The challenge isn’t often buying the helmet, it’s getting that helmet on every time and fitting it properly. I’ve learned the hard way– -after I pinched the skin on O’s chin a few times, I wasn’t even allowed to be the one helping him get it on!

Despite my lack of popularity with the boys on helmets, I’ve maintained hard rules: if the helmet isn’t on, the bike goes away and can’t be used for another 24 hours. I see helmets without buckled straps or hanging off the back of children’s heads everywhere I go. It wasn’t until I wrote a blog post about helmets when my oldest started to bike a few years back I learned to fit one properly.

Wearing a helmet reduces injury from bike & bike-motor vehicle accidents over 80% of the time. If the helmet isn’t snug and fit properly, it is far less likely to reduce injury. Hundreds of children and adults die annually in the US on their bicycles (primarily when struck by a car). Because 3/4 of all deaths on bicycles come from head injuries, wearing a properly fitting bike helmet can be a huge win. I hear over and over from children and parents in clinic that even though there is a helmet in the house their child isn’t always wearing it.

Further, when I review how important it is that the helmet fits, children and teens will often tell me they aren’t likely wearing it correctly.

Fitting A Bike Helmet

correct helmet fitYou want to ensure the helmet fits properly in 3 locations: above the eye, around the ear, and under the chin.

Eye: The helmet needs to be level on your child’s head (not back on their head like a baseball cap or yamaka) and needs to be positioned squarely on the forehead. Check with your fingers that the helmet is just 1-2 fingers above the eyebrow line.

Ear: The helmet straps should lie flat against their head (no twists!) and should form a “Y” shape just under the ear.

Chin: This is likely the point of most contention with children! The strap needs to be snug. Your child can help do the buckling (to avoid the dreaded pinched skin) but you make sure they are adjusted to the correct length. It should be snug enough to allow only a finger between the strap and chin with their mouth closed. When your child opens their mouth up wide, it should cause the helmet to move down on their head (see the video).

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Ask About Guns

Screen Shot 2013-06-18 at 9.45.50 AMIn my house we’re busy, working parents but we’ve certainly had lots of friends and relatives here at our house to play. No one has ever asked me if we had guns in the house. Last week my son visited a neighbor’s home and I didn’t ask before he went over.

I’ve asked friends and relatives if they had guns in their home in the past but I’m inconsistent–I may be out of practice. Asking a friend if there is a gun in the house can seem like a challenging and invasive task. I’ve written previously that asking about guns in the house for the first time can feel like asking about the color of someone’s underwear. We have to get over it.

An average of 8 kids and teens are killed by firearms every day and 42 additional children and teens are seriously injured.

It’s national ASK Day today thanks to the Center to Prevent Youth Violence. The statistics that got us here are staggering.

In April, for example, Bonnie Rochman at TIME wrote, “a 4-year-old picked up a loaded gun at a cook-out and accidentally killed the wife of a sheriff’s deputy in Tennessee. And on Monday, another 4-year-old shot and killed a 6-year-old friend as they played outside in a New Jersey neighborhood. ‘I’m sad for the children involved and their families, but I’m angry with whoever owns that gun and allowed a little child to get hold of it,’ neighbor Debbie Coto told the Associated Press.”

About 40% of homes in the US with children have guns and while only 1/2 of parents state they are concerned about guns, we know that 1 in 4 children who live in a home with a gun say they have touched it without their parents knowledge. Unintentional gun deaths are immensely tragic. Research shows that some 88% of children who are injured or killed by unintentional shootings are injured in their own home or the home of a friend or relative. The ASK campaign provides a great tips for how to ask about guns: Read full post »

Brothers And Sisters Who Fight

From Pop Strip

Lots of people ask me how my boys get along. I never know quite how to answer. They are pals most of the time, they play and invent and create games and fun together. But they also fight. I suppose I expect it as a mother but I admit that even as a pediatrician, ex school teacher, and younger sister in life, I sometimes don’t know exactly when to intervene and when to leave them alone to resolve disputes unassisted.

Our society seems to have more tolerance for sibling bullying than peer bullying whether in the schools or at the playground or at home. Traditionally we’re taught to expect sibling rivalries and often chalk it up as an expected or normal part of childhood. “Boys will be boys,” we say.

Some experts are urging us to think again.

Sibling violence is often minimized yet new research shows this violence and bullying can have lasting and serious mental health effects.

Parents and others often minimize the frequency and severity of aggressive behavior among siblings

Typically, I’m a stickler for a no-fighting-no-warzone type home. I hate the noise that comes with fighting and I hate the tension. When things escalate I tend to banish the boys to their rooms individually to help them cool off and make apologies and amends. Sometimes I let them sort it out themselves of course, as it can work wonders to plant myself squarely on the sideline. It’s luck of the draw though on how I respond from day to day–I have no clear system on when and why I intervene. I’ve been imperfect, too –in fact one tug-o-war between the boys with a bath towel landed my older son in the ER for stitches. I wasn’t even thinking about his mental health…

New research published today offers up some compelling data for we parents unsure how and when to respond or intervene when our children fight. We may need to get more involved. Researchers found that bullying at home from siblings can have lasting effects on mental health. And by the way, it isn’t always the oldest who bullies. Read full post »

End Of School

Screen Shot 2013-06-13 at 3.40.58 PMLast day of school this week. The backpack is nearly as big as his body; that’s no optical illusion and the body-to-backpack proportionality serves up a dutiful reminder for me that my little boy is still small. To me it feels like he’s perfectly diminutive amidst the big surroundings of his school– it’s boards and doors towering high enough to accommodate the 8th graders yet inclusive enough to welcome him gently into grade school.

It’s clear that as Kindergarten lands in the rear-view mirror my hearts aches. I know I’m supposed to celebrate his growth and accomplishment for finishing. And I do. Yet all I can think about today is the reality that now that he’s technically a first grader he is also a bona fide “school-aged boy.” In pediatrics that does mean something altogether different. In fact once a child is 6 years of age, we often tell families it’s fine to come in for well child care check-ups every other year, absent concerns, until a child is 11 years of age. Growth typically is steady and stable, children advance in school, and routines are made–this is “school-age.” Fortunately even though some of this time between 6 and 11 may be very routine, even in 1st grade, a friend reminded me last night, “They are still made to believe they are the center of the universe.”

Every parent ahead of us warns us about the speed of travel through parenthood. They reflect on the g-forces of time and the flash of light between Kindergarten and the day they find themselves standing in an archway with a mature child at the end of high school. Often those ahead of us couple the warning about the velocity with an instruction. “Savor this time,” they say. And so many of us do. We savor, we relish, we reflect, and we love. It isn’t always perfect and pretty, there are tantrums and accidents, mess-ups and failures, but we do savor and we really are present in the moment so often.

Sometimes I want to scream out that we parents (of young children) –we get it, too.

I’ll admit though that amidst the myriad of moments this past year that I have felt mindful and present, I’ve also had plenty of others where I lacked attention.

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CT Scans And Cancer Risk

T8--approx CT scan” Yesterday’s news,” my husband said when I shared a study published, well, yesterday. Yet what we do with yesterday’s information is of course the news today. A JAMA Pediatrics article found that the use of pediatric CT scans rose in the late 1990’s and early 2000’s. Further, research shows that these CT scans can increase risk for future cancer diagnoses. Authors calculated the risk: they estimate that for every 4 million pediatric CT scans preformed annually, some 4800 children will go on to develop cancer as a result. Like many studies published this decade, the study came with warnings for radiologists, pediatricians, and parents.  I have tips for parents and doctors included below.

CT scans use radiation and radiation exposure is linked to cancer.

That being said, CT scans also save lives and we’re learning to use them more judiciously. Since 2007, rates of CT scans in children are declining. Don’t let these risks and media reports today cause you refuse or forego diagnostic CT scans your children need. We just have to be strong advocates and smarter about how we use CT scans. Read full post »

Teens Girls And Pelvic Exams

Typically, teen girls do not need a pelvic exam until they are 21. Most parents are surprised to hear this, especially if they know their teen is sexually active.

About 1/2 of teen girls are sexually active during high school which puts them at risk for sexually transmitted infections (STI) and unwanted pregnancy. However, for routine prevention and care, girls rarely need an internal pelvic or speculum exam during high school. The American College of of Obstetricians and Gynecologists (ACOG) published a statement in 2012 outlining rationale for speculum exams and guidelines that support waiting until age 21 years in the absence of a health problem.

Some teens will need a visit with the gynecologist during their teen years because of health concerns, symptoms, or a desire for a long-acting reversible birth control like an IUD (intrauterine device) or implant. IUDs and implants are considered first-line birth control for teens now. The experts say these implantable devices methods are “top-tier contraceptives based on effectiveness, with pregnancy rates of less than 1% per year for perfect use and typical use. These contraceptives have the highest rates of satisfaction and continuation of all reversible contraceptives. Adolescents are at high risk of unintended pregnancy and may benefit from increased access to these methods.” Some IUD devices use hormones, some do not. Intrauterine devices can be inserted for up to 5-10 years depending on which type a teen chooses. In general, teens will need to see a gynecologist for an IUD placement.

The National Center For Health Statistics reported a near 50% decrease in teen pregnancy over the last 2 decades.

For routine care, teens should see their pediatrician every year for regular, routine well-teen care, teen vaccinations (including the HPV vaccine), and to obtain annual screening for sexually transmitted infections. Sexually active teen girls will need annual urine tests for gonorrhea and chlamydia and blood tests for HIV. We really want to grant teens access to private counseling, support, education, family planning, and well care during high school and don’t want them to erroneously worry about routinely having a pelvic exam. Read full post »

Hepatitis A Outbreak: A Vaccine For That

frozen smoothie berriesThe CDC declared an outbreak of Hepatitis A over the weekend that has affected over 30 people in 5 states. Preliminary information confirms the source of the outbreak stems from organic frozen berries that were sold at Costco stores (including stores in Washington) yet sickened people thus far are in Colorado, New Mexico, Arizona, Nevada, and California. No cases have been reported in Washington to date. The berries: Townsend Farms Organic Anti-Oxidant Blend, a frozen berry and pomegranate seed mix, have now been pulled from shelves and people who purchased these berries from February through May are being contacted.

The amazing thing about this outbreak: there’s been no reported cases of Hep A in children under age 18.

In the United States, Hepatitis A typically spreads through contaminated food handled by someone with the infection. Rates of Hepatitis A infection tops 5,000-10,000 cases annually in the US while they are far higher in the developing world because city water sources can get contaminated (see below). Hepatitis A vaccine is recommended before international travel.

The lack of children with infections from this outbreak is logical and potentially illustrative.

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