William G. Wilkoff

Until a couple of weeks ago I considered myself a COVID virgin. I had navigated a full 36 months without a positive test, despite cohabiting with my wife in a 2,500-square-foot house during her bout with the SARS-CoV-2 virus last year. I have been reasonably careful, a situational mask wearer, and good about avoiding poorly ventilated crowded spaces. Of course I was fully vaccinated but was waiting until we had gotten closer to a December trip before getting the newest booster.

I had always been quietly smug about my good luck. And, I was pretty sure that luck had been the major contributor to my run of good health. Nonetheless, in my private moments I often wondered if I somehow had inherited or acquired an unusual defense against the virus that had been getting the best of my peers. One rather far-fetched explanation that kept popping out of my subconscious involved my profuse and persistent runny nose.

Like a fair number in my demographic, I have what I have self-diagnosed as vasomotor rhinitis. In the cooler months and particularly when I am active outdoors, my nose runs like a faucet. I half-jokingly told my wife after a particularly drippy bike ride on a frigid November afternoon that even the most robust virus couldn’t possibly have survived the swim upstream against torrent of mucus splashing onto the handlebars of my bike.

A recent study published in the journal Cell suggests that my off-the-wall explanation for my COVID resistance wasn’t quite so hair-brained. The investigators haven’t found that septuagenarian adults with high-volume runny noses are drowning the SARS-Co- 2 virus before it can do any damage. However, the researchers did discover that, in general, young children seem to be having fewer and milder COVID infections because “infants mount a robust mucosal response” in their noses. This first line of defense seems to be more effective than in adults, where the virus can more easily slip through into the bloodstream, sometimes with a dramatic release of circulating cytokines, which occasionally create problems of their own. Children also release cytokines, but this is predominantly in their nose, where it appears to be less damaging. Interestingly, in children this initial response persists for around 300 days while in adults the immune response experiences a much more rapid decline. I guess this means we have to chalk one more up for snotty nose kids.

However, the results of this study also suggest that we should be giving more attention to the development of nasal vaccines. I recall that nearly 3 years ago, at the beginning of the pandemic, scientists using a ferret model had developed an effective nasal vaccine. I’m not sure why this faded out of the picture, but it feels like it’s time to turn the spotlight on this line of research again.

I suspect that in addition to being more effective, a nasal vaccine may gain more support among the antivaxxer population, many of whom I suspect are really needle phobics hiding behind a smoke screen of anti-science double talk.

At any rate, I will continue to search for articles that support my contention that my high-flow rhinorrhea is protecting me. I have always been told that a cold nose was the sign of a healthy dog. I’m just trying to prove that the same is true for us old guys with clear runny noses.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Until a couple of weeks ago I considered myself a COVID virgin. I had navigated a full 36 months without a positive test, despite cohabiting with my wife in a 2,500-square-foot house during her bout with the SARS-CoV-2 virus last year. I have been reasonably careful, a situational mask wearer, and good about avoiding poorly ventilated crowded spaces. Of course I was fully vaccinated but was waiting until we had gotten closer to a December trip before getting the newest booster.

I had always been quietly smug about my good luck. And, I was pretty sure that luck had been the major contributor to my run of good health. Nonetheless, in my private moments I often wondered if I somehow had inherited or acquired an unusual defense against the virus that had been getting the best of my peers. One rather far-fetched explanation that kept popping out of my subconscious involved my profuse and persistent runny nose.

Like a fair number in my demographic, I have what I have self-diagnosed as vasomotor rhinitis. In the cooler months and particularly when I am active outdoors, my nose runs like a faucet. I half-jokingly told my wife after a particularly drippy bike ride on a frigid November afternoon that even the most robust virus couldn’t possibly have survived the swim upstream against torrent of mucus splashing onto the handlebars of my bike.

A recent study published in the journal Cell suggests that my off-the-wall explanation for my COVID resistance wasn’t quite so hair-brained. The investigators haven’t found that septuagenarian adults with high-volume runny noses are drowning the SARS-Co- 2 virus before it can do any damage. However, the researchers did discover that, in general, young children seem to be having fewer and milder COVID infections because “infants mount a robust mucosal response” in their noses. This first line of defense seems to be more effective than in adults, where the virus can more easily slip through into the bloodstream, sometimes with a dramatic release of circulating cytokines, which occasionally create problems of their own. Children also release cytokines, but this is predominantly in their nose, where it appears to be less damaging. Interestingly, in children this initial response persists for around 300 days while in adults the immune response experiences a much more rapid decline. I guess this means we have to chalk one more up for snotty nose kids.

However, the results of this study also suggest that we should be giving more attention to the development of nasal vaccines. I recall that nearly 3 years ago, at the beginning of the pandemic, scientists using a ferret model had developed an effective nasal vaccine. I’m not sure why this faded out of the picture, but it feels like it’s time to turn the spotlight on this line of research again.

I suspect that in addition to being more effective, a nasal vaccine may gain more support among the antivaxxer population, many of whom I suspect are really needle phobics hiding behind a smoke screen of anti-science double talk.

At any rate, I will continue to search for articles that support my contention that my high-flow rhinorrhea is protecting me. I have always been told that a cold nose was the sign of a healthy dog. I’m just trying to prove that the same is true for us old guys with clear runny noses.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Until a couple of weeks ago I considered myself a COVID virgin. I had navigated a full 36 months without a positive test, despite cohabiting with my wife in a 2,500-square-foot house during her bout with the SARS-CoV-2 virus last year. I have been reasonably careful, a situational mask wearer, and good about avoiding poorly ventilated crowded spaces. Of course I was fully vaccinated but was waiting until we had gotten closer to a December trip before getting the newest booster.

I had always been quietly smug about my good luck. And, I was pretty sure that luck had been the major contributor to my run of good health. Nonetheless, in my private moments I often wondered if I somehow had inherited or acquired an unusual defense against the virus that had been getting the best of my peers. One rather far-fetched explanation that kept popping out of my subconscious involved my profuse and persistent runny nose.

Like a fair number in my demographic, I have what I have self-diagnosed as vasomotor rhinitis. In the cooler months and particularly when I am active outdoors, my nose runs like a faucet. I half-jokingly told my wife after a particularly drippy bike ride on a frigid November afternoon that even the most robust virus couldn’t possibly have survived the swim upstream against torrent of mucus splashing onto the handlebars of my bike.

A recent study published in the journal Cell suggests that my off-the-wall explanation for my COVID resistance wasn’t quite so hair-brained. The investigators haven’t found that septuagenarian adults with high-volume runny noses are drowning the SARS-Co- 2 virus before it can do any damage. However, the researchers did discover that, in general, young children seem to be having fewer and milder COVID infections because “infants mount a robust mucosal response” in their noses. This first line of defense seems to be more effective than in adults, where the virus can more easily slip through into the bloodstream, sometimes with a dramatic release of circulating cytokines, which occasionally create problems of their own. Children also release cytokines, but this is predominantly in their nose, where it appears to be less damaging. Interestingly, in children this initial response persists for around 300 days while in adults the immune response experiences a much more rapid decline. I guess this means we have to chalk one more up for snotty nose kids.

However, the results of this study also suggest that we should be giving more attention to the development of nasal vaccines. I recall that nearly 3 years ago, at the beginning of the pandemic, scientists using a ferret model had developed an effective nasal vaccine. I’m not sure why this faded out of the picture, but it feels like it’s time to turn the spotlight on this line of research again.

I suspect that in addition to being more effective, a nasal vaccine may gain more support among the antivaxxer population, many of whom I suspect are really needle phobics hiding behind a smoke screen of anti-science double talk.

At any rate, I will continue to search for articles that support my contention that my high-flow rhinorrhea is protecting me. I have always been told that a cold nose was the sign of a healthy dog. I’m just trying to prove that the same is true for us old guys with clear runny noses.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Let’s pretend for a moment that you receive a call from one of your college roommates who thanks to his family connections has become a venture capitalist in California. His group is considering investing in a start-up that is developing a handheld instrument that it claims will use artificial intelligence to diagnose ear infections far more accurately than the human eye. He wonders if you would like to help him evaluate the company’s proposal and offers you a small percentage of the profits for your efforts should they choose to invest.

Your former roommate has done enough research on his own to understand that otitis media makes up a large chunk of a pediatrician’s workload and that making an accurate diagnosis can often be difficult in a struggling child. He describes his own experience watching a frustrated pediatrician attempting to remove wax from his child’s ear and eventually prescribing antibiotics “to be safe.”

You agree and review the prospectus, which includes a paper from a peer-reviewed journal. What you discover is that the investigators used more than 600 high-resolution images of tympanic membranes taken “during operative myringotomy and tympanostomy tube placement” and the findings at tympanocentesis to train a neural network.

Once trained, the model they developed could differentiate with 95% accuracy between an image of a tympanic membrane that covered a normal middle ear from one that merely contained fluid and from one that contained infected fluid. When these same images were shown to 39 clinicians, more than half of which were pediatricians and included both faculty-level staff and trainees, the average diagnostic accuracy was 65%.

The prospectus includes prediction that this technology could easily be developed into a handheld instrument similar to a traditional otoscope, which could then be linked to the operator’s smartphone, giving the clinician an instant treat or no-treat answer.

Now, remember you have nothing to lose except maybe a friendship. How would you advise your old college roommate?

My advice to your college buddy would be one of caution! Yes, there is a potential big upside because there is a real need for a device that could provide a diagnostic accuracy that this AI model promises. While I suspect that AI will always be more accurate in diagnosis using static images, I bet that most people, clinicians and nonclinicians, could improve their accuracy by linking photos with diagnoses with an hour of practice.

However, evaluating a high-resolution photograph taken through an operative scope inserted into the cerumenless ear canal of a sedated, afrebrile child is several orders of magnitude less difficult than the real-world environment in which the diagnosis of otitis media is usually made.

If the venture capitalists were still interested in getting into the otitis media marketplace, you might suggest they look into companies that have already developed image capture otoscopes. At this point I could only find one on the Internet that was portable and it certainly isn’t small-child friendly. Once we have a tool that can capture images in real-world situations, the next step is to train AI systems to interpret them using the approach these researchers have developed. I bet it can be done. It will be only a matter of time ... and money.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Let’s pretend for a moment that you receive a call from one of your college roommates who thanks to his family connections has become a venture capitalist in California. His group is considering investing in a start-up that is developing a handheld instrument that it claims will use artificial intelligence to diagnose ear infections far more accurately than the human eye. He wonders if you would like to help him evaluate the company’s proposal and offers you a small percentage of the profits for your efforts should they choose to invest.

Your former roommate has done enough research on his own to understand that otitis media makes up a large chunk of a pediatrician’s workload and that making an accurate diagnosis can often be difficult in a struggling child. He describes his own experience watching a frustrated pediatrician attempting to remove wax from his child’s ear and eventually prescribing antibiotics “to be safe.”

You agree and review the prospectus, which includes a paper from a peer-reviewed journal. What you discover is that the investigators used more than 600 high-resolution images of tympanic membranes taken “during operative myringotomy and tympanostomy tube placement” and the findings at tympanocentesis to train a neural network.

Once trained, the model they developed could differentiate with 95% accuracy between an image of a tympanic membrane that covered a normal middle ear from one that merely contained fluid and from one that contained infected fluid. When these same images were shown to 39 clinicians, more than half of which were pediatricians and included both faculty-level staff and trainees, the average diagnostic accuracy was 65%.

The prospectus includes prediction that this technology could easily be developed into a handheld instrument similar to a traditional otoscope, which could then be linked to the operator’s smartphone, giving the clinician an instant treat or no-treat answer.

Now, remember you have nothing to lose except maybe a friendship. How would you advise your old college roommate?

My advice to your college buddy would be one of caution! Yes, there is a potential big upside because there is a real need for a device that could provide a diagnostic accuracy that this AI model promises. While I suspect that AI will always be more accurate in diagnosis using static images, I bet that most people, clinicians and nonclinicians, could improve their accuracy by linking photos with diagnoses with an hour of practice.

However, evaluating a high-resolution photograph taken through an operative scope inserted into the cerumenless ear canal of a sedated, afrebrile child is several orders of magnitude less difficult than the real-world environment in which the diagnosis of otitis media is usually made.

If the venture capitalists were still interested in getting into the otitis media marketplace, you might suggest they look into companies that have already developed image capture otoscopes. At this point I could only find one on the Internet that was portable and it certainly isn’t small-child friendly. Once we have a tool that can capture images in real-world situations, the next step is to train AI systems to interpret them using the approach these researchers have developed. I bet it can be done. It will be only a matter of time ... and money.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Let’s pretend for a moment that you receive a call from one of your college roommates who thanks to his family connections has become a venture capitalist in California. His group is considering investing in a start-up that is developing a handheld instrument that it claims will use artificial intelligence to diagnose ear infections far more accurately than the human eye. He wonders if you would like to help him evaluate the company’s proposal and offers you a small percentage of the profits for your efforts should they choose to invest.

Your former roommate has done enough research on his own to understand that otitis media makes up a large chunk of a pediatrician’s workload and that making an accurate diagnosis can often be difficult in a struggling child. He describes his own experience watching a frustrated pediatrician attempting to remove wax from his child’s ear and eventually prescribing antibiotics “to be safe.”

You agree and review the prospectus, which includes a paper from a peer-reviewed journal. What you discover is that the investigators used more than 600 high-resolution images of tympanic membranes taken “during operative myringotomy and tympanostomy tube placement” and the findings at tympanocentesis to train a neural network.

Once trained, the model they developed could differentiate with 95% accuracy between an image of a tympanic membrane that covered a normal middle ear from one that merely contained fluid and from one that contained infected fluid. When these same images were shown to 39 clinicians, more than half of which were pediatricians and included both faculty-level staff and trainees, the average diagnostic accuracy was 65%.

The prospectus includes prediction that this technology could easily be developed into a handheld instrument similar to a traditional otoscope, which could then be linked to the operator’s smartphone, giving the clinician an instant treat or no-treat answer.

Now, remember you have nothing to lose except maybe a friendship. How would you advise your old college roommate?

My advice to your college buddy would be one of caution! Yes, there is a potential big upside because there is a real need for a device that could provide a diagnostic accuracy that this AI model promises. While I suspect that AI will always be more accurate in diagnosis using static images, I bet that most people, clinicians and nonclinicians, could improve their accuracy by linking photos with diagnoses with an hour of practice.

However, evaluating a high-resolution photograph taken through an operative scope inserted into the cerumenless ear canal of a sedated, afrebrile child is several orders of magnitude less difficult than the real-world environment in which the diagnosis of otitis media is usually made.

If the venture capitalists were still interested in getting into the otitis media marketplace, you might suggest they look into companies that have already developed image capture otoscopes. At this point I could only find one on the Internet that was portable and it certainly isn’t small-child friendly. Once we have a tool that can capture images in real-world situations, the next step is to train AI systems to interpret them using the approach these researchers have developed. I bet it can be done. It will be only a matter of time ... and money.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

I can dimly recall watching Queen Elizabeth’s coronation on a very small black and white television screen. Even in monochrome it was a riveting event. Recently, the Queen celebrated her Platinum Jubilee, marking her 70-year reign. Apparently it was a multiday event with all the trappings, floating above an undercurrent of scandal and intrigue. I had better things to do than I did as a 7-year-old entranced by the novelty of a neighbor’s television set.

But, it turns out that I had missed the opportunity to see live and in color a royal meltdown starring the Queen’s great-grandson, 4-year-old Prince Louis. Not to worry. It remains on video archives for our education and pleasure ad infinitum. His performance was no more dramatic than what you have seen numerous times in the checkout line of the grocery store. However, this meltdown was on the world stage in the front row of the royal box and performed in various venues on each day of a 4-day event.

As long as you weren’t his parents, Kate Middleton and Prince William, the meltdown had its moments of hilarity. Louis made full use of his youthful and plastic face, creating a wide variety of taunts and responses to his mother’s praiseworthy and understated attempts at regaining control. Of course, the British press and every armchair parent with a Twitter account had a field day contributing their explanations and advice.

For example, here’s the headline on an international news website that caught my eye: “Royal reveals why Prince Louis was so ‘mischievous’ during the Jubilee”. In the article, a fellow royal and former rugby star who was sitting directly behind the little Prince during one of his performances chalked up the 4-year-old’s behavior to a “sugar high” resulting from the ample supply of sweets available behind the royal box.

Nowhere in the article is there a question of whether the “sugar high” is a science-based phenomenon. In fact, the reporter assumes we all know it exists and writes that “parents across the globe can probably [read: definitely] relate.”

I’m curious: How do you respond when a parent in the office explains the child’s behavior as the result of a “sugar high”? Or when you’re at a cookout and someone makes a comment that makes it obvious that they believe that “sugar highs” are real? Do you immediately pause the conversation and launch into a short but tasteful observation that you know of no scientific studies that sugar can cause a high? Or, figuring that in the face of an overwhelming burden of old wives’ tales it’s not worth mounting a rebuttal, do you pretend you didn’t hear the comment?

Or am I completely off base because your experience has left you convinced that despite the lack of supporting studies the “sugar high” phenomenon exists? Maybe you even include it on your list of explanations and remedies for pediatric misbehaviors. I am ready to listen, but it will take some heavy lifting to convince me.

I suspect your response to offhand comments about “sugar highs” is similar to mine. It depends on the situation. If I think there are obvious and correctable causes for the child’s misbehavior such as sleep deprivation or a mismatch between parental expectation and the child’s tolerance for a stimulating environment I will include in my parenting advice the comment, “Sugar highs probably don’t exist.”

On the other hand, if I’m tired and think my observation will fall on deaf ears I let the conversation drift. I worry that my silence will be interpreted as a confirmation of an old wives’ tale. What I really don’t want to do is perpetuate a myth that may prevent some children from getting the care they need.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

I can dimly recall watching Queen Elizabeth’s coronation on a very small black and white television screen. Even in monochrome it was a riveting event. Recently, the Queen celebrated her Platinum Jubilee, marking her 70-year reign. Apparently it was a multiday event with all the trappings, floating above an undercurrent of scandal and intrigue. I had better things to do than I did as a 7-year-old entranced by the novelty of a neighbor’s television set.

But, it turns out that I had missed the opportunity to see live and in color a royal meltdown starring the Queen’s great-grandson, 4-year-old Prince Louis. Not to worry. It remains on video archives for our education and pleasure ad infinitum. His performance was no more dramatic than what you have seen numerous times in the checkout line of the grocery store. However, this meltdown was on the world stage in the front row of the royal box and performed in various venues on each day of a 4-day event.

As long as you weren’t his parents, Kate Middleton and Prince William, the meltdown had its moments of hilarity. Louis made full use of his youthful and plastic face, creating a wide variety of taunts and responses to his mother’s praiseworthy and understated attempts at regaining control. Of course, the British press and every armchair parent with a Twitter account had a field day contributing their explanations and advice.

For example, here’s the headline on an international news website that caught my eye: “Royal reveals why Prince Louis was so ‘mischievous’ during the Jubilee”. In the article, a fellow royal and former rugby star who was sitting directly behind the little Prince during one of his performances chalked up the 4-year-old’s behavior to a “sugar high” resulting from the ample supply of sweets available behind the royal box.

Nowhere in the article is there a question of whether the “sugar high” is a science-based phenomenon. In fact, the reporter assumes we all know it exists and writes that “parents across the globe can probably [read: definitely] relate.”

I’m curious: How do you respond when a parent in the office explains the child’s behavior as the result of a “sugar high”? Or when you’re at a cookout and someone makes a comment that makes it obvious that they believe that “sugar highs” are real? Do you immediately pause the conversation and launch into a short but tasteful observation that you know of no scientific studies that sugar can cause a high? Or, figuring that in the face of an overwhelming burden of old wives’ tales it’s not worth mounting a rebuttal, do you pretend you didn’t hear the comment?

Or am I completely off base because your experience has left you convinced that despite the lack of supporting studies the “sugar high” phenomenon exists? Maybe you even include it on your list of explanations and remedies for pediatric misbehaviors. I am ready to listen, but it will take some heavy lifting to convince me.

I suspect your response to offhand comments about “sugar highs” is similar to mine. It depends on the situation. If I think there are obvious and correctable causes for the child’s misbehavior such as sleep deprivation or a mismatch between parental expectation and the child’s tolerance for a stimulating environment I will include in my parenting advice the comment, “Sugar highs probably don’t exist.”

On the other hand, if I’m tired and think my observation will fall on deaf ears I let the conversation drift. I worry that my silence will be interpreted as a confirmation of an old wives’ tale. What I really don’t want to do is perpetuate a myth that may prevent some children from getting the care they need.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

I can dimly recall watching Queen Elizabeth’s coronation on a very small black and white television screen. Even in monochrome it was a riveting event. Recently, the Queen celebrated her Platinum Jubilee, marking her 70-year reign. Apparently it was a multiday event with all the trappings, floating above an undercurrent of scandal and intrigue. I had better things to do than I did as a 7-year-old entranced by the novelty of a neighbor’s television set.

But, it turns out that I had missed the opportunity to see live and in color a royal meltdown starring the Queen’s great-grandson, 4-year-old Prince Louis. Not to worry. It remains on video archives for our education and pleasure ad infinitum. His performance was no more dramatic than what you have seen numerous times in the checkout line of the grocery store. However, this meltdown was on the world stage in the front row of the royal box and performed in various venues on each day of a 4-day event.

As long as you weren’t his parents, Kate Middleton and Prince William, the meltdown had its moments of hilarity. Louis made full use of his youthful and plastic face, creating a wide variety of taunts and responses to his mother’s praiseworthy and understated attempts at regaining control. Of course, the British press and every armchair parent with a Twitter account had a field day contributing their explanations and advice.

For example, here’s the headline on an international news website that caught my eye: “Royal reveals why Prince Louis was so ‘mischievous’ during the Jubilee”. In the article, a fellow royal and former rugby star who was sitting directly behind the little Prince during one of his performances chalked up the 4-year-old’s behavior to a “sugar high” resulting from the ample supply of sweets available behind the royal box.

Nowhere in the article is there a question of whether the “sugar high” is a science-based phenomenon. In fact, the reporter assumes we all know it exists and writes that “parents across the globe can probably [read: definitely] relate.”

I’m curious: How do you respond when a parent in the office explains the child’s behavior as the result of a “sugar high”? Or when you’re at a cookout and someone makes a comment that makes it obvious that they believe that “sugar highs” are real? Do you immediately pause the conversation and launch into a short but tasteful observation that you know of no scientific studies that sugar can cause a high? Or, figuring that in the face of an overwhelming burden of old wives’ tales it’s not worth mounting a rebuttal, do you pretend you didn’t hear the comment?

Or am I completely off base because your experience has left you convinced that despite the lack of supporting studies the “sugar high” phenomenon exists? Maybe you even include it on your list of explanations and remedies for pediatric misbehaviors. I am ready to listen, but it will take some heavy lifting to convince me.

I suspect your response to offhand comments about “sugar highs” is similar to mine. It depends on the situation. If I think there are obvious and correctable causes for the child’s misbehavior such as sleep deprivation or a mismatch between parental expectation and the child’s tolerance for a stimulating environment I will include in my parenting advice the comment, “Sugar highs probably don’t exist.”

On the other hand, if I’m tired and think my observation will fall on deaf ears I let the conversation drift. I worry that my silence will be interpreted as a confirmation of an old wives’ tale. What I really don’t want to do is perpetuate a myth that may prevent some children from getting the care they need.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

In the early 1970’s, the three letters that a pediatric house officer hated to see on a slip returning from the lab were Q.N.S. Quality Not Sufficient meant that the minutes, which seemed like hours, you had invested torturing some poor sick child to obtain just a few cc’s of blood had been wasted. It also meant returning to the patient’s crib or bedside to explain to the child and her parents that the torture you had promised was over for the day was in fact not over.

Tourniquets were fished out of lapel buttonholes, and the search for a decent vein had to begin all over again. If the child was chubby or bloated with retained fluid, those veins were invisible. If the child had been ill for weeks – particularly if the patient had been on chemotherapy – all of the good veins had been blown or had clotted days ago.

Many of the patients were saintly and eerily cooperative despite your fumbling attempts at venipuncture, but most were not. Some parents were so supportive of your efforts that you wanted to hug them when the ordeal was over (and you did). A few parents amped up the tension at the bedside so much that you wanted to ask them to leave (but you didn’t). If a parent was understandably incapable of effectively restraining the child, you needed to find an experienced nurse to help. A few of the best nurses were so good that the house officer merely needed to hold the needle still, and the child was repositioned in just the right orientation so that the puncture occurred miraculously.

There were some last ditch efforts at phlebotomy that were so ghastly that you had to ask the parents to leave. I don’t know if the infamous internal jugular stick is still used, but it wasn’t pretty. And it was almost as frightening for the physician holding the needle as it was for the patient. Even in the big teaching hospitals, dedicated phlebotomists hadn’t been invented yet. A few nurses had earned reputations as good vein finders, but for the most part it was on-the-job training for the house officers.

It was not until 1973 that Dr. John Broviac’s central line catheters became available in some hospitals and 1979 until Dr. Robert Hickman’s version appeared. It took a few more years before techniques were perfected for safely drawing specimens from these lines that had been originally intended for infusion. But for me and my cohort of house officers and our unfortunate patients, it was years too late. I am sure that caring for hospitalized pediatric cancer patients today continues to be dominated by challenges. But for those of us tasked with drawing blood from patients without the benefit of central line catheters, it was gut wrenching.

Those battles for a few cc’s of blood left their scars. I have seldom ordered any blood test without asking myself whether there wasn’t a bloodless way of assessing the patient’s condition. Or couldn’t we just do the test on a drop or two of blood? Of course, as I as finishing my training, more tests were downsized so that they could be done “micro.” But as you know, getting enough blood from a heel stick or finger prick isn’t always as easy as it sounds. If the child is shocky or cold, a good blood flow is hard to obtain. Warming helps but squeezing doesn’t because tissue juices can dilute the sample, and the trauma of squeezing can contaminate the sample.

A study published in the American Journal of Clinical Pathology raises the question of how accurately even a single drop of blood reflects what is going on in the patient’s total blood pool (“Drop by drop variation in the cellular components of fingerprick blood: Implications for point-of-care diagnostic development” [Am J Clin Pathol. 2015 Dec;144(6):885-94]). Two bioengineers from Rice University discovered that six successive drops of blood from a single finger prick varied by a significant amount when analyzed for a variety of cellular components. For example, the drop-to-drop variability for hemoglobin was five times that of a sample collected by venipuncture.

You and I may dream of the day when just a drop will do it and we can put our needles away for good. Unfortunately, for now, the answer is that a single drop of blood is a Q.N.S.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”

In the early 1970’s, the three letters that a pediatric house officer hated to see on a slip returning from the lab were Q.N.S. Quality Not Sufficient meant that the minutes, which seemed like hours, you had invested torturing some poor sick child to obtain just a few cc’s of blood had been wasted. It also meant returning to the patient’s crib or bedside to explain to the child and her parents that the torture you had promised was over for the day was in fact not over.

Tourniquets were fished out of lapel buttonholes, and the search for a decent vein had to begin all over again. If the child was chubby or bloated with retained fluid, those veins were invisible. If the child had been ill for weeks – particularly if the patient had been on chemotherapy – all of the good veins had been blown or had clotted days ago.

Many of the patients were saintly and eerily cooperative despite your fumbling attempts at venipuncture, but most were not. Some parents were so supportive of your efforts that you wanted to hug them when the ordeal was over (and you did). A few parents amped up the tension at the bedside so much that you wanted to ask them to leave (but you didn’t). If a parent was understandably incapable of effectively restraining the child, you needed to find an experienced nurse to help. A few of the best nurses were so good that the house officer merely needed to hold the needle still, and the child was repositioned in just the right orientation so that the puncture occurred miraculously.

There were some last ditch efforts at phlebotomy that were so ghastly that you had to ask the parents to leave. I don’t know if the infamous internal jugular stick is still used, but it wasn’t pretty. And it was almost as frightening for the physician holding the needle as it was for the patient. Even in the big teaching hospitals, dedicated phlebotomists hadn’t been invented yet. A few nurses had earned reputations as good vein finders, but for the most part it was on-the-job training for the house officers.

It was not until 1973 that Dr. John Broviac’s central line catheters became available in some hospitals and 1979 until Dr. Robert Hickman’s version appeared. It took a few more years before techniques were perfected for safely drawing specimens from these lines that had been originally intended for infusion. But for me and my cohort of house officers and our unfortunate patients, it was years too late. I am sure that caring for hospitalized pediatric cancer patients today continues to be dominated by challenges. But for those of us tasked with drawing blood from patients without the benefit of central line catheters, it was gut wrenching.

Those battles for a few cc’s of blood left their scars. I have seldom ordered any blood test without asking myself whether there wasn’t a bloodless way of assessing the patient’s condition. Or couldn’t we just do the test on a drop or two of blood? Of course, as I as finishing my training, more tests were downsized so that they could be done “micro.” But as you know, getting enough blood from a heel stick or finger prick isn’t always as easy as it sounds. If the child is shocky or cold, a good blood flow is hard to obtain. Warming helps but squeezing doesn’t because tissue juices can dilute the sample, and the trauma of squeezing can contaminate the sample.

A study published in the American Journal of Clinical Pathology raises the question of how accurately even a single drop of blood reflects what is going on in the patient’s total blood pool (“Drop by drop variation in the cellular components of fingerprick blood: Implications for point-of-care diagnostic development” [Am J Clin Pathol. 2015 Dec;144(6):885-94]). Two bioengineers from Rice University discovered that six successive drops of blood from a single finger prick varied by a significant amount when analyzed for a variety of cellular components. For example, the drop-to-drop variability for hemoglobin was five times that of a sample collected by venipuncture.

You and I may dream of the day when just a drop will do it and we can put our needles away for good. Unfortunately, for now, the answer is that a single drop of blood is a Q.N.S.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”

In the early 1970’s, the three letters that a pediatric house officer hated to see on a slip returning from the lab were Q.N.S. Quality Not Sufficient meant that the minutes, which seemed like hours, you had invested torturing some poor sick child to obtain just a few cc’s of blood had been wasted. It also meant returning to the patient’s crib or bedside to explain to the child and her parents that the torture you had promised was over for the day was in fact not over.

Tourniquets were fished out of lapel buttonholes, and the search for a decent vein had to begin all over again. If the child was chubby or bloated with retained fluid, those veins were invisible. If the child had been ill for weeks – particularly if the patient had been on chemotherapy – all of the good veins had been blown or had clotted days ago.

Many of the patients were saintly and eerily cooperative despite your fumbling attempts at venipuncture, but most were not. Some parents were so supportive of your efforts that you wanted to hug them when the ordeal was over (and you did). A few parents amped up the tension at the bedside so much that you wanted to ask them to leave (but you didn’t). If a parent was understandably incapable of effectively restraining the child, you needed to find an experienced nurse to help. A few of the best nurses were so good that the house officer merely needed to hold the needle still, and the child was repositioned in just the right orientation so that the puncture occurred miraculously.

There were some last ditch efforts at phlebotomy that were so ghastly that you had to ask the parents to leave. I don’t know if the infamous internal jugular stick is still used, but it wasn’t pretty. And it was almost as frightening for the physician holding the needle as it was for the patient. Even in the big teaching hospitals, dedicated phlebotomists hadn’t been invented yet. A few nurses had earned reputations as good vein finders, but for the most part it was on-the-job training for the house officers.

It was not until 1973 that Dr. John Broviac’s central line catheters became available in some hospitals and 1979 until Dr. Robert Hickman’s version appeared. It took a few more years before techniques were perfected for safely drawing specimens from these lines that had been originally intended for infusion. But for me and my cohort of house officers and our unfortunate patients, it was years too late. I am sure that caring for hospitalized pediatric cancer patients today continues to be dominated by challenges. But for those of us tasked with drawing blood from patients without the benefit of central line catheters, it was gut wrenching.

Those battles for a few cc’s of blood left their scars. I have seldom ordered any blood test without asking myself whether there wasn’t a bloodless way of assessing the patient’s condition. Or couldn’t we just do the test on a drop or two of blood? Of course, as I as finishing my training, more tests were downsized so that they could be done “micro.” But as you know, getting enough blood from a heel stick or finger prick isn’t always as easy as it sounds. If the child is shocky or cold, a good blood flow is hard to obtain. Warming helps but squeezing doesn’t because tissue juices can dilute the sample, and the trauma of squeezing can contaminate the sample.

A study published in the American Journal of Clinical Pathology raises the question of how accurately even a single drop of blood reflects what is going on in the patient’s total blood pool (“Drop by drop variation in the cellular components of fingerprick blood: Implications for point-of-care diagnostic development” [Am J Clin Pathol. 2015 Dec;144(6):885-94]). Two bioengineers from Rice University discovered that six successive drops of blood from a single finger prick varied by a significant amount when analyzed for a variety of cellular components. For example, the drop-to-drop variability for hemoglobin was five times that of a sample collected by venipuncture.

You and I may dream of the day when just a drop will do it and we can put our needles away for good. Unfortunately, for now, the answer is that a single drop of blood is a Q.N.S.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”

Okay, I admit that from time to time I have embellished the anecdotes that I include in these letters. Sometimes, I feel I need to make sure that you are paying attention. But this time, I am relating this story in its true, unvarnished state.

Two mature women with whom I am acquainted (No, one was not my wife!) had just finished their habitual Saturday morning walk through a wooded upper middle class neighborhood here in town. It was nine o’clock in the morning and the sun was shining. Suddenly, a mangy-looking fox trotted out of the woods and down the road toward them. Aware that from time to time local raccoons, skunks, and foxes have tested positive for rabies, these women began to run and flagged down the first car they saw, and without a word hopped in the back seat.

The surprised occupants of the vehicle were two mature men. You might call them strangers, but here in Maine, we don’t have any strangers. We have tourists. If a fellow Mainer doesn’t know you, he probably knows two people with whom you are acquainted.

As the women began to breathlessly explain their actions, one of the women felt a searing pain in her right thigh and assumed she had torn a muscle as she sprinted away from the fox. Within a few hundred yards, the car began to fill with smoke. Believing that the vehicle was on fire, all four occupants tumbled out into the street like four carnival clowns.

It quickly became clear that the cause of the smoke and the searing pain was that the woman’s pants were on fire. Throwing all caution and modesty to the wind, she quickly shed her pants in the middle of the road and in full view of these men, with whom it turns out she does share several acquaintances.

The source of the fire was the woman’s cell phone. The resulting injury was a palm-size, painful, deep, second-degree burn of her anterior thigh. In a quick Internet search, you will discover several very similar stories – minus the fox and the strangers. Some of the victims were children.

It turns out some cell phones have a tendency to spontaneously explode and/or catch fire. There seems to be no common factor in the events, although some of the ultrathin and flexible cell phones may be more prone to conflagration. However, the victim in our scenario has a storied past with cell phones. She has dropped them in the toilet at least once (history is a little unclear here on the exact number). On another occasion, she placed one in the sink of a public restroom, we can assume to prevent a second or third toilet submersion. As she approached the sink to retrieve it, the clever water-saving faucet – sensing her presence – turned itself on. But in the fox and fire incident, she denies any previous submersions or unusual events with this particular phone. A lawyer is now involved.

So while you and I as pediatricians may be concerned about the relationship between cell phones and health of our patients primarily because cell phones can be a dangerous distraction for young drivers, cyclists, and pedestrians, I share this anecdote to make you aware of another of their health hazards. You also may want to reconsider where you carry your cell phone.

I am not worried myself. I have a little flip phone for which I pay $100 for 500 minutes of usage a year, way more than I need or use. It couldn’t be considered a smartphone as its only noteworthy skill is taking pictures of the inside of my pants pocket. I suspect that its battery must be so small and impotent that even if it decides to self-immolate, I doubt I will notice. However, I do worry about scraggly-looking foxes meandering through my neighborhood.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” Email him at pdnews@frontlinemedcom.com.

Okay, I admit that from time to time I have embellished the anecdotes that I include in these letters. Sometimes, I feel I need to make sure that you are paying attention. But this time, I am relating this story in its true, unvarnished state.

Two mature women with whom I am acquainted (No, one was not my wife!) had just finished their habitual Saturday morning walk through a wooded upper middle class neighborhood here in town. It was nine o’clock in the morning and the sun was shining. Suddenly, a mangy-looking fox trotted out of the woods and down the road toward them. Aware that from time to time local raccoons, skunks, and foxes have tested positive for rabies, these women began to run and flagged down the first car they saw, and without a word hopped in the back seat.

The surprised occupants of the vehicle were two mature men. You might call them strangers, but here in Maine, we don’t have any strangers. We have tourists. If a fellow Mainer doesn’t know you, he probably knows two people with whom you are acquainted.

As the women began to breathlessly explain their actions, one of the women felt a searing pain in her right thigh and assumed she had torn a muscle as she sprinted away from the fox. Within a few hundred yards, the car began to fill with smoke. Believing that the vehicle was on fire, all four occupants tumbled out into the street like four carnival clowns.

It quickly became clear that the cause of the smoke and the searing pain was that the woman’s pants were on fire. Throwing all caution and modesty to the wind, she quickly shed her pants in the middle of the road and in full view of these men, with whom it turns out she does share several acquaintances.

The source of the fire was the woman’s cell phone. The resulting injury was a palm-size, painful, deep, second-degree burn of her anterior thigh. In a quick Internet search, you will discover several very similar stories – minus the fox and the strangers. Some of the victims were children.

It turns out some cell phones have a tendency to spontaneously explode and/or catch fire. There seems to be no common factor in the events, although some of the ultrathin and flexible cell phones may be more prone to conflagration. However, the victim in our scenario has a storied past with cell phones. She has dropped them in the toilet at least once (history is a little unclear here on the exact number). On another occasion, she placed one in the sink of a public restroom, we can assume to prevent a second or third toilet submersion. As she approached the sink to retrieve it, the clever water-saving faucet – sensing her presence – turned itself on. But in the fox and fire incident, she denies any previous submersions or unusual events with this particular phone. A lawyer is now involved.

So while you and I as pediatricians may be concerned about the relationship between cell phones and health of our patients primarily because cell phones can be a dangerous distraction for young drivers, cyclists, and pedestrians, I share this anecdote to make you aware of another of their health hazards. You also may want to reconsider where you carry your cell phone.

I am not worried myself. I have a little flip phone for which I pay $100 for 500 minutes of usage a year, way more than I need or use. It couldn’t be considered a smartphone as its only noteworthy skill is taking pictures of the inside of my pants pocket. I suspect that its battery must be so small and impotent that even if it decides to self-immolate, I doubt I will notice. However, I do worry about scraggly-looking foxes meandering through my neighborhood.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” Email him at pdnews@frontlinemedcom.com.

Okay, I admit that from time to time I have embellished the anecdotes that I include in these letters. Sometimes, I feel I need to make sure that you are paying attention. But this time, I am relating this story in its true, unvarnished state.

Two mature women with whom I am acquainted (No, one was not my wife!) had just finished their habitual Saturday morning walk through a wooded upper middle class neighborhood here in town. It was nine o’clock in the morning and the sun was shining. Suddenly, a mangy-looking fox trotted out of the woods and down the road toward them. Aware that from time to time local raccoons, skunks, and foxes have tested positive for rabies, these women began to run and flagged down the first car they saw, and without a word hopped in the back seat.

The surprised occupants of the vehicle were two mature men. You might call them strangers, but here in Maine, we don’t have any strangers. We have tourists. If a fellow Mainer doesn’t know you, he probably knows two people with whom you are acquainted.

As the women began to breathlessly explain their actions, one of the women felt a searing pain in her right thigh and assumed she had torn a muscle as she sprinted away from the fox. Within a few hundred yards, the car began to fill with smoke. Believing that the vehicle was on fire, all four occupants tumbled out into the street like four carnival clowns.

It quickly became clear that the cause of the smoke and the searing pain was that the woman’s pants were on fire. Throwing all caution and modesty to the wind, she quickly shed her pants in the middle of the road and in full view of these men, with whom it turns out she does share several acquaintances.

The source of the fire was the woman’s cell phone. The resulting injury was a palm-size, painful, deep, second-degree burn of her anterior thigh. In a quick Internet search, you will discover several very similar stories – minus the fox and the strangers. Some of the victims were children.

It turns out some cell phones have a tendency to spontaneously explode and/or catch fire. There seems to be no common factor in the events, although some of the ultrathin and flexible cell phones may be more prone to conflagration. However, the victim in our scenario has a storied past with cell phones. She has dropped them in the toilet at least once (history is a little unclear here on the exact number). On another occasion, she placed one in the sink of a public restroom, we can assume to prevent a second or third toilet submersion. As she approached the sink to retrieve it, the clever water-saving faucet – sensing her presence – turned itself on. But in the fox and fire incident, she denies any previous submersions or unusual events with this particular phone. A lawyer is now involved.

So while you and I as pediatricians may be concerned about the relationship between cell phones and health of our patients primarily because cell phones can be a dangerous distraction for young drivers, cyclists, and pedestrians, I share this anecdote to make you aware of another of their health hazards. You also may want to reconsider where you carry your cell phone.

I am not worried myself. I have a little flip phone for which I pay $100 for 500 minutes of usage a year, way more than I need or use. It couldn’t be considered a smartphone as its only noteworthy skill is taking pictures of the inside of my pants pocket. I suspect that its battery must be so small and impotent that even if it decides to self-immolate, I doubt I will notice. However, I do worry about scraggly-looking foxes meandering through my neighborhood.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” Email him at pdnews@frontlinemedcom.com.

You may not have read the much ballyhooed article about selective eating in preschoolers that was distributed to the media prior to publication because it was buried online, but I bet that you have heard or read something about it (“Psychological and Psychosocial Impairment in Preschoolers with Selective Eating” by Zucker et al., [Pediatrics. 2015 Aug 3. doi: 10.1542/peds.2014-2386]). In fact, there were so many news stories, both print and electronic, and the headlines were so divergent that my wife asked me if there were actually two studies released simultaneously.

Some news reports emphasized the reassuring observation by the authors that most picky eating preschoolers will mature into older children with less selective eating habits. However, others highlighted the authors’ primary message that young children with severe selective eating behavior often have significant psychopathology (anxiety, depression, attention-deficit/hyperactivity disorder), and those with even moderate picky eating may be manifesting the effects of living in a dysfunctional family.

The authors recommend that we pediatricians rethink our traditional party line on selective eating. Instead of simply administering frequent doses of reassurance to the parents of “picky eaters,” we should begin to view even moderate selective eating as a red flag that the child and his or her family need help.

This shift in emphasis is long overdue. I always have felt that problem picky eating is an example of normal infant behavior that has been mismanaged by the child’s family. And in some cases physicians also must share in the blame for not having given the most appropriate advice in a timely fashion to parents who have complained about their child’s selective eating.

It would help if we all took a deep breath, stepped back a few steps, and looked at the bigger picture. We are talking about eating, one of the critical life-sustaining activities. One can understand why most infants are wired to initially reject new tastes and textures. Neophobia – fear of anything new – has probably saved millions of infants from the serious consequences of unsupervised foraging. But don’t you think that these aversions are for the most part weak enough to be easily overridden by every child’s innate drive for self-preservation? “I don’t like how this smells, tastes, looks, or feels, but darn it, I’m getting hungry, and I have to eat to survive. So I will eat it.”

The problem is that while some parents can agree with that line of reasoning, many parents, including those who buy the rationale, can’t bring themselves to quietly accept their new role as merely being providers of a healthy diet. For 9 or 10 months, it was their job to get food into their child because the poor little thing lacked the skill to do it himself. But once a child can chew solids and put things in his mouth, he can not only survive but thrive if someone will simply present him a balanced diet of appropriate consistency and volume … and then step back and shut up.

Obviously, this transition is difficult to a significant number of parents. In many cases, it is because no one has told them that toddlers will appear to eat less than they did as infants or that allowing children unlimited access to energy-containing fluid will blunt their appetites. Or that it is okay that a child only eats one-and-a-half meals on some days. Or that it if you wait long enough without resorting to coaxing, bribing, or begging, a child will eat what his body needs. And failing to be patient and instead making an issue of eating (or not eating), what began as a normal infant aversion to new tastes and textures can spiral into a divisive family catastrophe.

Are there some infants who are so hypersensitive to new tastes and textures that waiting will endanger their health? If they exist, in my experience they are very rare. However, there are certainly toddlers who have become hypersensitive. In my opinion, they were always vulnerable and would have been much less of a problem had they been properly managed early on when they were just a little neophobic.

Are there clues during the child’s infancy that his family is more likely to have significant difficulty making the transition from “feeding” to “presenting” food? This new study observed that high maternal anxiety was frequently observed in both moderate and severe selective-eating children. This is another example of how we need to be aware from a very early stage when a parent is anxious or depressed. The failure to identify and see that those issues are addressed can seriously impair the whole family’s wellness.

Finally, on the other end of the spectrum, is usual garden variety selective eating outgrown? Have you tried to host a dinner party lately? I don’t mean a pot luck supper – I’m talking about a sit-down meal with a single menu. My wife and I have almost given up trying. “Martha is gluten free (without a diagnosis), Bob is watching his cholesterol, Rachel is pretty sure she is lactose intolerant, and you know Charlie hates vegetables. The Wilsons only do organic and are vegetarians.”

Next time we are considering mailing them gift certificates for their favorite restaurants along with an invitation to come over to our place for an after dinner drink. BYOB.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”

You may not have read the much ballyhooed article about selective eating in preschoolers that was distributed to the media prior to publication because it was buried online, but I bet that you have heard or read something about it (“Psychological and Psychosocial Impairment in Preschoolers with Selective Eating” by Zucker et al., [Pediatrics. 2015 Aug 3. doi: 10.1542/peds.2014-2386]). In fact, there were so many news stories, both print and electronic, and the headlines were so divergent that my wife asked me if there were actually two studies released simultaneously.

Some news reports emphasized the reassuring observation by the authors that most picky eating preschoolers will mature into older children with less selective eating habits. However, others highlighted the authors’ primary message that young children with severe selective eating behavior often have significant psychopathology (anxiety, depression, attention-deficit/hyperactivity disorder), and those with even moderate picky eating may be manifesting the effects of living in a dysfunctional family.

The authors recommend that we pediatricians rethink our traditional party line on selective eating. Instead of simply administering frequent doses of reassurance to the parents of “picky eaters,” we should begin to view even moderate selective eating as a red flag that the child and his or her family need help.

This shift in emphasis is long overdue. I always have felt that problem picky eating is an example of normal infant behavior that has been mismanaged by the child’s family. And in some cases physicians also must share in the blame for not having given the most appropriate advice in a timely fashion to parents who have complained about their child’s selective eating.

It would help if we all took a deep breath, stepped back a few steps, and looked at the bigger picture. We are talking about eating, one of the critical life-sustaining activities. One can understand why most infants are wired to initially reject new tastes and textures. Neophobia – fear of anything new – has probably saved millions of infants from the serious consequences of unsupervised foraging. But don’t you think that these aversions are for the most part weak enough to be easily overridden by every child’s innate drive for self-preservation? “I don’t like how this smells, tastes, looks, or feels, but darn it, I’m getting hungry, and I have to eat to survive. So I will eat it.”

The problem is that while some parents can agree with that line of reasoning, many parents, including those who buy the rationale, can’t bring themselves to quietly accept their new role as merely being providers of a healthy diet. For 9 or 10 months, it was their job to get food into their child because the poor little thing lacked the skill to do it himself. But once a child can chew solids and put things in his mouth, he can not only survive but thrive if someone will simply present him a balanced diet of appropriate consistency and volume … and then step back and shut up.

Obviously, this transition is difficult to a significant number of parents. In many cases, it is because no one has told them that toddlers will appear to eat less than they did as infants or that allowing children unlimited access to energy-containing fluid will blunt their appetites. Or that it is okay that a child only eats one-and-a-half meals on some days. Or that it if you wait long enough without resorting to coaxing, bribing, or begging, a child will eat what his body needs. And failing to be patient and instead making an issue of eating (or not eating), what began as a normal infant aversion to new tastes and textures can spiral into a divisive family catastrophe.

Are there some infants who are so hypersensitive to new tastes and textures that waiting will endanger their health? If they exist, in my experience they are very rare. However, there are certainly toddlers who have become hypersensitive. In my opinion, they were always vulnerable and would have been much less of a problem had they been properly managed early on when they were just a little neophobic.

Are there clues during the child’s infancy that his family is more likely to have significant difficulty making the transition from “feeding” to “presenting” food? This new study observed that high maternal anxiety was frequently observed in both moderate and severe selective-eating children. This is another example of how we need to be aware from a very early stage when a parent is anxious or depressed. The failure to identify and see that those issues are addressed can seriously impair the whole family’s wellness.

Finally, on the other end of the spectrum, is usual garden variety selective eating outgrown? Have you tried to host a dinner party lately? I don’t mean a pot luck supper – I’m talking about a sit-down meal with a single menu. My wife and I have almost given up trying. “Martha is gluten free (without a diagnosis), Bob is watching his cholesterol, Rachel is pretty sure she is lactose intolerant, and you know Charlie hates vegetables. The Wilsons only do organic and are vegetarians.”

Next time we are considering mailing them gift certificates for their favorite restaurants along with an invitation to come over to our place for an after dinner drink. BYOB.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”

You may not have read the much ballyhooed article about selective eating in preschoolers that was distributed to the media prior to publication because it was buried online, but I bet that you have heard or read something about it (“Psychological and Psychosocial Impairment in Preschoolers with Selective Eating” by Zucker et al., [Pediatrics. 2015 Aug 3. doi: 10.1542/peds.2014-2386]). In fact, there were so many news stories, both print and electronic, and the headlines were so divergent that my wife asked me if there were actually two studies released simultaneously.

Some news reports emphasized the reassuring observation by the authors that most picky eating preschoolers will mature into older children with less selective eating habits. However, others highlighted the authors’ primary message that young children with severe selective eating behavior often have significant psychopathology (anxiety, depression, attention-deficit/hyperactivity disorder), and those with even moderate picky eating may be manifesting the effects of living in a dysfunctional family.

The authors recommend that we pediatricians rethink our traditional party line on selective eating. Instead of simply administering frequent doses of reassurance to the parents of “picky eaters,” we should begin to view even moderate selective eating as a red flag that the child and his or her family need help.

This shift in emphasis is long overdue. I always have felt that problem picky eating is an example of normal infant behavior that has been mismanaged by the child’s family. And in some cases physicians also must share in the blame for not having given the most appropriate advice in a timely fashion to parents who have complained about their child’s selective eating.

It would help if we all took a deep breath, stepped back a few steps, and looked at the bigger picture. We are talking about eating, one of the critical life-sustaining activities. One can understand why most infants are wired to initially reject new tastes and textures. Neophobia – fear of anything new – has probably saved millions of infants from the serious consequences of unsupervised foraging. But don’t you think that these aversions are for the most part weak enough to be easily overridden by every child’s innate drive for self-preservation? “I don’t like how this smells, tastes, looks, or feels, but darn it, I’m getting hungry, and I have to eat to survive. So I will eat it.”

The problem is that while some parents can agree with that line of reasoning, many parents, including those who buy the rationale, can’t bring themselves to quietly accept their new role as merely being providers of a healthy diet. For 9 or 10 months, it was their job to get food into their child because the poor little thing lacked the skill to do it himself. But once a child can chew solids and put things in his mouth, he can not only survive but thrive if someone will simply present him a balanced diet of appropriate consistency and volume … and then step back and shut up.

Obviously, this transition is difficult to a significant number of parents. In many cases, it is because no one has told them that toddlers will appear to eat less than they did as infants or that allowing children unlimited access to energy-containing fluid will blunt their appetites. Or that it is okay that a child only eats one-and-a-half meals on some days. Or that it if you wait long enough without resorting to coaxing, bribing, or begging, a child will eat what his body needs. And failing to be patient and instead making an issue of eating (or not eating), what began as a normal infant aversion to new tastes and textures can spiral into a divisive family catastrophe.

Are there some infants who are so hypersensitive to new tastes and textures that waiting will endanger their health? If they exist, in my experience they are very rare. However, there are certainly toddlers who have become hypersensitive. In my opinion, they were always vulnerable and would have been much less of a problem had they been properly managed early on when they were just a little neophobic.

Are there clues during the child’s infancy that his family is more likely to have significant difficulty making the transition from “feeding” to “presenting” food? This new study observed that high maternal anxiety was frequently observed in both moderate and severe selective-eating children. This is another example of how we need to be aware from a very early stage when a parent is anxious or depressed. The failure to identify and see that those issues are addressed can seriously impair the whole family’s wellness.

Finally, on the other end of the spectrum, is usual garden variety selective eating outgrown? Have you tried to host a dinner party lately? I don’t mean a pot luck supper – I’m talking about a sit-down meal with a single menu. My wife and I have almost given up trying. “Martha is gluten free (without a diagnosis), Bob is watching his cholesterol, Rachel is pretty sure she is lactose intolerant, and you know Charlie hates vegetables. The Wilsons only do organic and are vegetarians.”

Next time we are considering mailing them gift certificates for their favorite restaurants along with an invitation to come over to our place for an after dinner drink. BYOB.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”

The number of parents asking their pediatricians to stray from the recommended immunization schedule by spreading out the vaccines is increasing, and so is the number of pediatricians who are agreeing to follow these spaced-out schedules.

One of the two reasons most often given by pediatricians for agreeing to the less than optimal immunization schedules is that by showing a willingness to compromise, that physician may be helping to build a trusting relationship with these families. The other reason is a concern – let’s be honest and call it a fear – that a dissatisfied family will move its care to another physician/provider.

When we scratch the surface of these two rationales, neither seems to make much sense. The conflict over immunization spacing comes to a head at the 2-month well-child visit recommended call for six injections. If the infant has had an unremarkable neonatal course, there may not have been any situation in which the physician was forced to demonstrate her trustworthiness. As long as she has dressed professionally, showed up on time for appointments, washed her hands, and appeared genuinely interested in the child’s well-being, that’s about all she has had to do.

The physician may give the impression that she can be trusted, but real trust is usually something that must accumulate over time, in monthly – or more likely yearly – increments. Occasionally a crisis allows the physician to behave so heroically that her route to a trusting relationship is compressed to just a few hours, but fortunately these crises are rare.

Does agreeing to an unnecessary and unsubstantiated diversion from the recommended immunization schedule play a role in trust building? It may signal that the physician is willing to compromise, which in some situations may not be a bad attribute. For example, the mother who has struggled and failed at breastfeeding her 6 weeks despite everyone’s best efforts will appreciate her pediatrician’s willingness to compromise. But should compromise of scientifically validated practices really be one of the cornerstones of a physician-patient relationship?

I have never had a family request that the immunization schedule be spread out for their second child because they have seen for themselves that the process is not what they have feared. I gave all the immunizations myself, and my administration style was quick and matter-of-fact. The problem, of course, is getting hesitant parents up to and over that hurdle of the 2-month visit. Unfortunately, the evidence seems to be that education and extra time and reassurance are of little value in getting them to that point of trust.

The more difficult issue is a physician’s fear that by failing to agree to a spaced-out schedule, she will open a spigot and families will flow out of her practice to other more compromising providers. Is this just an ego thing? No one likes to feel rejected. Will the feared patient exodus seriously depress the physician’s income or will it be merely a trickle that can be ignored? Obviously, the answer varies from community to community. Do families have so many options that they will easily be able to find a provider who is eager to grow his or her practice, and is less concerned about the immunization level of the community? Or, is the pediatrician so busy that a firm adherence to the standard schedule might provide a welcome opportunity to have a more manageable panel size, and at the same time shift the patient mix toward families that don’t require the extra time in fruitless “educational” discussions?

These are questions that don’t seem to be getting asked. What are the numbers? Is the loss of patients just an irrational fear for physicians created by an irrational fear of a small segment of the population? If the physician practices in a group, could her fear of patient loss be eased if the entire group committed itself to following the standard immunization schedule? Are group members discussing this issue among themselves and with their practice managers? Or, is everyone just spacing out?

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at pdnews@frontlinemedcom.com. Scan this QR code to read similar articles or go to pediatricnews.com.

The number of parents asking their pediatricians to stray from the recommended immunization schedule by spreading out the vaccines is increasing, and so is the number of pediatricians who are agreeing to follow these spaced-out schedules.

One of the two reasons most often given by pediatricians for agreeing to the less than optimal immunization schedules is that by showing a willingness to compromise, that physician may be helping to build a trusting relationship with these families. The other reason is a concern – let’s be honest and call it a fear – that a dissatisfied family will move its care to another physician/provider.

When we scratch the surface of these two rationales, neither seems to make much sense. The conflict over immunization spacing comes to a head at the 2-month well-child visit recommended call for six injections. If the infant has had an unremarkable neonatal course, there may not have been any situation in which the physician was forced to demonstrate her trustworthiness. As long as she has dressed professionally, showed up on time for appointments, washed her hands, and appeared genuinely interested in the child’s well-being, that’s about all she has had to do.

The physician may give the impression that she can be trusted, but real trust is usually something that must accumulate over time, in monthly – or more likely yearly – increments. Occasionally a crisis allows the physician to behave so heroically that her route to a trusting relationship is compressed to just a few hours, but fortunately these crises are rare.

Does agreeing to an unnecessary and unsubstantiated diversion from the recommended immunization schedule play a role in trust building? It may signal that the physician is willing to compromise, which in some situations may not be a bad attribute. For example, the mother who has struggled and failed at breastfeeding her 6 weeks despite everyone’s best efforts will appreciate her pediatrician’s willingness to compromise. But should compromise of scientifically validated practices really be one of the cornerstones of a physician-patient relationship?

I have never had a family request that the immunization schedule be spread out for their second child because they have seen for themselves that the process is not what they have feared. I gave all the immunizations myself, and my administration style was quick and matter-of-fact. The problem, of course, is getting hesitant parents up to and over that hurdle of the 2-month visit. Unfortunately, the evidence seems to be that education and extra time and reassurance are of little value in getting them to that point of trust.

The more difficult issue is a physician’s fear that by failing to agree to a spaced-out schedule, she will open a spigot and families will flow out of her practice to other more compromising providers. Is this just an ego thing? No one likes to feel rejected. Will the feared patient exodus seriously depress the physician’s income or will it be merely a trickle that can be ignored? Obviously, the answer varies from community to community. Do families have so many options that they will easily be able to find a provider who is eager to grow his or her practice, and is less concerned about the immunization level of the community? Or, is the pediatrician so busy that a firm adherence to the standard schedule might provide a welcome opportunity to have a more manageable panel size, and at the same time shift the patient mix toward families that don’t require the extra time in fruitless “educational” discussions?

These are questions that don’t seem to be getting asked. What are the numbers? Is the loss of patients just an irrational fear for physicians created by an irrational fear of a small segment of the population? If the physician practices in a group, could her fear of patient loss be eased if the entire group committed itself to following the standard immunization schedule? Are group members discussing this issue among themselves and with their practice managers? Or, is everyone just spacing out?

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at pdnews@frontlinemedcom.com. Scan this QR code to read similar articles or go to pediatricnews.com.

The number of parents asking their pediatricians to stray from the recommended immunization schedule by spreading out the vaccines is increasing, and so is the number of pediatricians who are agreeing to follow these spaced-out schedules.

One of the two reasons most often given by pediatricians for agreeing to the less than optimal immunization schedules is that by showing a willingness to compromise, that physician may be helping to build a trusting relationship with these families. The other reason is a concern – let’s be honest and call it a fear – that a dissatisfied family will move its care to another physician/provider.

When we scratch the surface of these two rationales, neither seems to make much sense. The conflict over immunization spacing comes to a head at the 2-month well-child visit recommended call for six injections. If the infant has had an unremarkable neonatal course, there may not have been any situation in which the physician was forced to demonstrate her trustworthiness. As long as she has dressed professionally, showed up on time for appointments, washed her hands, and appeared genuinely interested in the child’s well-being, that’s about all she has had to do.

The physician may give the impression that she can be trusted, but real trust is usually something that must accumulate over time, in monthly – or more likely yearly – increments. Occasionally a crisis allows the physician to behave so heroically that her route to a trusting relationship is compressed to just a few hours, but fortunately these crises are rare.

Does agreeing to an unnecessary and unsubstantiated diversion from the recommended immunization schedule play a role in trust building? It may signal that the physician is willing to compromise, which in some situations may not be a bad attribute. For example, the mother who has struggled and failed at breastfeeding her 6 weeks despite everyone’s best efforts will appreciate her pediatrician’s willingness to compromise. But should compromise of scientifically validated practices really be one of the cornerstones of a physician-patient relationship?

I have never had a family request that the immunization schedule be spread out for their second child because they have seen for themselves that the process is not what they have feared. I gave all the immunizations myself, and my administration style was quick and matter-of-fact. The problem, of course, is getting hesitant parents up to and over that hurdle of the 2-month visit. Unfortunately, the evidence seems to be that education and extra time and reassurance are of little value in getting them to that point of trust.

The more difficult issue is a physician’s fear that by failing to agree to a spaced-out schedule, she will open a spigot and families will flow out of her practice to other more compromising providers. Is this just an ego thing? No one likes to feel rejected. Will the feared patient exodus seriously depress the physician’s income or will it be merely a trickle that can be ignored? Obviously, the answer varies from community to community. Do families have so many options that they will easily be able to find a provider who is eager to grow his or her practice, and is less concerned about the immunization level of the community? Or, is the pediatrician so busy that a firm adherence to the standard schedule might provide a welcome opportunity to have a more manageable panel size, and at the same time shift the patient mix toward families that don’t require the extra time in fruitless “educational” discussions?

These are questions that don’t seem to be getting asked. What are the numbers? Is the loss of patients just an irrational fear for physicians created by an irrational fear of a small segment of the population? If the physician practices in a group, could her fear of patient loss be eased if the entire group committed itself to following the standard immunization schedule? Are group members discussing this issue among themselves and with their practice managers? Or, is everyone just spacing out?

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at pdnews@frontlinemedcom.com. Scan this QR code to read similar articles or go to pediatricnews.com.