Rx For Parenting Today

Children with Prolonged Fevers

I was talking with a grandmother today who was concerned that her three-year-old granddaughter was still  running a fever after four days. I asked her what the pediatrician had said and she said the doctor had just prescribed antibiotics over the telephone. I urged the grandmother to be sure her daughter took the child to the pediatrician today. No little three-year-old should ever have a fever for four days without being seen by a doctor. How did the doctor know that the child didn't have a stiff neck, a dangerous rash, or a bulging ear drum? No child should ever be given antibiotics without being seen. I shudder when I hear about doctors who do this. I also shudder when I hear pediatricians talk about telemedicine. How do they know what a child really has by just looking at a TV camera and seeing the child? Technology has many  places, but certainly not in pediatrics. I fear that many of our young doctors are being taught just with technology and clinic and bedside teaching, as I had in medical school, may be a thing of the past. I also spoke with a young  doctor last week who thinks technology has all the answers, but after I told him about some of the unusual problems I have found, I hope I changed his mind. One child I told him about was a little boy who had been followed for several months by his pediatrician because of a swollen gland in his neck. The doctor had not referred him to an oncologist which was what I did right away because I didn't like the feel of the node. I could not have felt the node if all I had was a picture on a TV screen. The little boy had Hodgkin's disease and needed immediate treatment. I worried that the prolonged time the previous doctor had been following the child would make a difference in his life expectancy. Another case I told him about was a little girl who woke up at night with pain in her hip. On examination, there was nothing really visible, except when I moved her leg to the side it hurt her. I thought the child had rheumatoid arthritis and she did. Telemedicine would have been no help.

Urinary Problems in Children

I was talking a few days ago with the mother of a thirteen-year-old, who was thinking about looking for a new pediatrician. I asked her what kind of yearly exam the girl's doctor did and she said he had never looked at her daughter below the waist. Also, he had never ordered a urinalysis or done a basic hemoglobin. I was astounded. Every child, including little ones, should have a yearly urinalysis. This is particularly true if there is a history of diabetes in the family or of urinary problems. If there is an unexplained high fever, a urine specimen should also be checked. For little ones, there are special urinary collection bags that every medical office should have if children are being seen.

I have found a surprising number of urinary problems in patients because not only was this stressed in medical school, but also because a family member had an undetected abnormal kidney that was removed when she was in her teens. A wonderful, older woman family doctor found it on her first examination and the hydronephrotic kidney was removed the next day by a urologist in Los Angeles. He was legendary and on the Board of Urology. I had one muscle disease patient in his teens, who was referred to me by his pediatrician. On examining his abdomen I felt a mass, so I asked the mother to give him a laxative that night and an enema if necessary and bring him back the next day. The mass was still there, so I spoke with the teenager's pediatrician and asked if I could refer the patient to a good urologist at UC Medical Center in San Francisco. The doctor said that was fine and the urologist found an abnormal kidney that had to be removed. The pediatrician asked me, "How did you discover the kidney problem?"

When I told my adult daughter about this she said "Well, I guess you just did a physical examination."   Yes, that is what I did even thought the teenage was large and used a wheelchair. I had a wonderful examining table that would go up and down, so the mother and I were able to slide the  teenager onto the examining table. A good, complete physical examination can bring many unexpected findings, as can a yearly urinalysis.

Child Abuse Has a Life-Long Effect

 Caring for children who have been physically or emotionally abused is one of the hardest things I have had to do as a pediatrician. One report stated that "More than a third of the women in state prisons and jails say they were physically or sexually abused as children." Studies have shown that prostitutes also have had a high incidence of sexual abuse as children. Almost all the agencies set up to protect children fight hard to maintain an adequate staff because of lack of funding. If House speaker, Paul Ryan, has his way the safety net for children will be eliminated and there are never enough foster families for the number of children who need them. These are children who have been taken from their parents because of mistreatment, a parent is mentally ill, or in prison.  In some of these foster families, when they are not carefully monitored, the children are also abused.  Relatives who take over the care of a family member's child because of mental illness, prison or other reasons are often not carefully checked out and they too, may abuse the children. Many kids go from foster home to foster home, which social workers call foster care "drift". Just think of the damage that can happen to a child who has never had a secure home or loving  parents.

Several adults have told me of both their emotional and in some cases physical abuse. Each adult has suffered life-long effects. Even the best psychiatric help has not completely erased the terrible trauma these adults suffered as children.  Neglect is another form of child abuse and parents who are too busy with their careers or social life to spend any time with their children,  cause damage that may be difficult for a psychologist or psychiatrist to help.  I often wondered why some parents, whose children I cared for, even had children. They didn't spend any time with them and the children were expected to be "perfect." These parents caused great harm and even finding good psychiatric help for the kids did not completely undo the damage. I have a long-term follow-up on many of the children and although some seem outwardly to be O.K., I know the terrible price they  have paid for their parents' neglect.

Parenting the Siblings of a Child with a Disability

Parenting a child with special needs or a disability can be almost a full-time job. With frequent trips to doctors, physical therapists, school meetings, and many other tasks, brothers and sisters can feel left out. In the many sibling group discussions I have held over the years, I have been amazed at some of the things the children have told me. Many feel guilty that in some way they caused their sibling's problem. This is particularly true if the disability is due to an accident. Others feel angry  because their parents spend so little time with them. They understand that their brother or sister needs to go to the doctors and other places, but the kids still feel they deserve some attention from their parents and they are right. Often the siblings told me  they had to do extra chores or had to help their brother and sister more than they felt was right.

Many brothers and sisters use attention-getting mechanisms in order to attract their parents' attention. Some have emotional withdrawal, some act out, and others become angry. If as a parent you are noticing a change in the behavior of a brother or sister, I would suggest taking the child to a park or getting some ice cream and talking about what is going on. Some frequent one-to-one time can make all the difference in the world. Talking to even small children can make a difference. One mother asked me, "Can you really talk to little children about problems?" "You can always try", I answered and she was very surprised  when it worked.

I think as a parent you have to be very sensitive about how much responsibility you are asking the siblings to take on. One woman told me she decided early on that she didn't want children because she felt as though she had raised her brothers and sisters,since the parents were so involved with a child who had a serious progressive disorder. Even children with a disability should have some kind of chore. Discipline, too, should be the same for all the children. I have found that many children with a disability are very skillful about manipulating others. It can be a useful skill for them sometimes, but it can greatly hurt the siblings. So watching out for anger, guilt, jealousy, loneliness and grief in the brothers and sisters and trying to find some answers can make a great difference. Sometimes, family or individual therapy is needed.

Why Toddlers Misbehave

We have all seen toddlers screaming and acting out in the grocery store and many want to take the parents to task for having such a naughty child. Often a child is just hungry and tired and needs to go home for some food and a nap. However, there are multiple reasons why little ones misbehave and it may be a medical or emotional one. In my new parenting book, Prescription (Rx) for Parenting, I have a section on reasons why little ones act out. Children with disabilities, such as autism or Asperger's Syndrome often have a hard time following rules and being restrained. Having someone watch the little child while a parent does errands and shopping may be the best plan. All children, even those with special needs need structure and parents who are not afraid to set limits and say "No". I finding saying "No" seems to be hard for many parents today. They want to just be their children's friends.   Kids do not want their parents to be friends; they want parents who act like adults, because this makes them feel loved and secure.

Some of the other reasons little ones misbehave is because they are indulged or spoiled; they need more sleep, there is a medical or emotional problem; or they are frustrated or uncomfortable. The list goes on and on. If misbehavior becomes a real problem, then a good physical examination is needed, as well as a complete blood count, a urinalysis and sometimes special tests to see if there is a metabolic or allergy problem. Sometimes a child just needs some quiet time or is bored. There is usually a reason and if parents are  truly aware of what is going on with a little one, there should be an answer.

Good Information for Parents about Apps, iPhones and Androids

An article I wish all parents could read appeared in the 12/24/15 New York Times written by Brian Chen. He is both a parent and an expert on all the gadgets available to kids these days. He  discusses which gadgets are the safest for kids to use, so they can not order countless dollars of merchandise available through different apps and also which ones can protect kids from having access to vault apps. He states that "vault apps are phone apps with sexting capabilities that disguise themselves as calculator programs and other mundane tools."  Surveys have shown that 22% of seventh graders admit to sexting. That is beyond my understanding that a 13-year-old would be so desperate for a boyfriend that she would send a nude picture of herself to a boy. Where are the parents? Are they talking about sexting to their daughters?

Mr. Chen states that iPhones work better than androids to help parents set up controls, so their children can not get into sites that  they should not access. He mentions a Family Sharing setting on the iPhone that allows parents to have some control over what their kids are doing.   He describes a feature on the Family Sharing called "As to Buy" where parents  are notified if a child wanted to purchase something available on an app. They can approve or not approve. There is also a feature called Restrictions that can be helpful to parents. If kids have lots to do, such as chores and homework and some fun time, they would not have so much time to order things on an iPhone or play all the available  games. It is interesting to me that Steve Jobs and other computer experts did not or do not allow their children to have access to all these gadgets until they were much older.

When Parents Decide to Be their Children's Doctors

I am always amazed when I hear accounts of parents who make medical decisions about their children. A friend recently told me about a mother who knew her teenage son had a curvature of the spine or scoliosis and instead of having been seen and followed by an orthopedic surgeon, she ordered a back brace on the Internet! A back brace, if it is needed, should be made by a skilled orthotist or brace-maker. How a mother decided she could take care of her son's spine problem is beyond my understanding. If the curvature became worse, it could cause both heart and breathing problems. At that point, I wonder if the mother would finally decide to seek medical help. Scoliosis surgery can often be avoided if a child or teenager is followed closely by an orthopedist and an appropriate brace prescribed.

Then there are the parents discussed in an article in the 12/29/15 New York Times. The news item states that parents who refuse immunizations for their children are generally "white, well-educated, and affluent." I wonder about the "well-educated" part, because an educated parent would know about the dangers of death from polio, measles, whooping cough and the other communicable diseases. If  a parent had ever seen a child die from one of these diseases or spend life in a wheelchair or tied to a breathing apparatus, immunizations would be given when they are recommended by the American Academy of  Pediatrics.  I spent the first two months of my internship in the polio section at San Francisco Children's Hospital. As a 25-year-old who had just finished medical school, it was a hard and often terrifying experience. How glad I was that Dr. Salk had developed the polio vaccine before my two children were born. Dr. Salk and Dr. Sabin saved countless children's lives with their discoveries, as well as keeping millions of other children from having to walk in braces, be in wheelchairs or on life-support. Dr. Andrew Wakefield, who reported vaccines caused autism, was stripped of his British medical license and his report completely refuted. So if parents think they know more than medical doctors and researchers, I worry about the future for their children.

My New Year's Wish for All Parents in 2016

When I think about my 50 years of practicing pediatrics, some remarkable parents stand out. These parents were able to love their children without reservation, while allowing them to follow their own paths, unless it was a destructive one. Today, I find that far too many parents make decisions about what their children should do and be. I heard someone ask a parent what he wanted his child to be? I don't think parents have the right to decide what a child should do or be as an adult. I know five physicians who each lost a child to suicide. In one case, the father insisted that his very creative son become a physician. The youth neither had the ability or the interest in becoming an M.D. and ended his life as a twenty-year-old.

I think helping a child develop his or her special interest and ability is what parenting is all about. Even a child with autism or another disability will have special qualities that can be supported. I had a severely disability teenage patient who had the remarkable ability to remember everyone's telephone numbers and important dates, such as birthdays. This gave him special recognition which he greatly treasured. Some children have artistic ability that can be developed, some are computer kids, and on and on. If a child is so programmed that he or she has no time to dream or tinker with mechanical things, as did Steve Jobs, we would not have some of the remarkable inventions we have today. Not every child should go to college, be a professional or make a lot of money. We need more trade schools and support of the arts.

All children need to feel loved and secure and be taught respect and empathy for others. Making money is not what life is all about and yet that seems to be the goal of many parents today. Having cared for children from extremely wealthy families, I know the price they have paid; anorexia, bulimia, depression, and suicide  were far too common. So my hope is that 2016 can bring much happiness to parents and their children with lots of fun, good communication, and hugs.  Happy New Year!