Is Your Child Too Sick for School? Or, When Doctor Land’s Kid Threw Up On The Teacher.

It was about 7:30 one morning 10 years ago when, while rushing to clean up breakfast, make lunches, dry my hair and convince three slow kids to move along I heard my son say, “Mom, I don’t feel so good!”

We have all had mornings where we have heard those words but – what do we do next? How do we know when to keep our kids home and when to send them off to school?

Part of our job as parents is to get our kids to school on time everyday. Doing so helps ensure their success in school. We know this and yet, the decision about when a child is too sick for school can be a very difficult one.

While your decision must involve a healthy dose of common sense, here are some basic guidelines to help you:

  • You child should not attend school if they have had a fever over 100.4 in the last 24 hours.
  • If your child is contagious to other kids (some examples are: fever, vomiting, diarrhea, uncontrollable coughing, red and oozing eyes) she should stay home.
  • Keep your child home if they seem too sick to be able to participate actively in school.

Here are more specific examples (each with links to help you know when it is time to see a doctor):


If your child has had a fever in the last 24 hours, the child is likely contagious and does not feel well enough to participate in school.


While one isolated urp is unlikely to be a reason to keep them home, vomiting right before school or twice within 24 hours should be a cause for staying home under your care. If vomiting is paired with belly pain, fever, decreased urination or an inability to take any liquids, see a doctor.


Some kids have chronically loose stools (often from drinking juice) but, if their poops have been watery or bloody or they have had three bowel movements in 24 hours you should consider keeping them home. Diarrhea can be from an infection.

Red eyes:

If the white of the eye is just slightly pink and the discharge is watery, your child should be good to go. However, if the eye is red, hurts or has yellow/green discharge, it is time to see a doctor.

Sore throat:

If a sore throat is accompanied by fever, swollen glands, rash or stomach ache, then you should arrange for a strep throat test. If the sore throat is only paired with a bit of runny nose, the child may be well enough for school.


A new rash on a child that does not feel well should be evaluated by a doctor. If the rash is accompanied by a fever, a doctor must see the child.

We know that school-aged kids get sick an average of 6-10 times a year – that’s a lot! There are a few things you can do to keep your child as healthy as possible:

  • Teach them to wash their hands often. Most childhood illnesses are spread through germs shared by touch (one child wipes their runny nose and turns a doorknob and the next child who touches the door knob gets the cooties). Helpful tip: they will do a more effective job of washing if they sing the ABC song twice through while sudsing up!
  • Fully vaccinate your child including the yearly influenza vaccine. Vaccines are safe and effective.

Know that, despite your best efforts sometimes your choice will turn out to be wrong. You may send a sicker-than-you-realized kid off to school and get called by the school office. Or, you may keep your child home, only to be stuck with a way-too-healthy child bouncing around your home! To help avoid repeating that last scenario, I always try to make staying home very unappealing: no TV, no play dates and not too much fun with mom.

Sometimes children begin to try to avoid going to school. This can become a real problem with chronic absences impeding their ability to achieve in school. If you are struggling with a child who often seems to be asking to stay home, check out this toolkit from Attendance Works and this helpful resource on school avoidance from Kaiser Permanente for more guidance.

On that morning that I had a decade ago, I looked at my kiddo and said: “You have no fever, you aren’t throwing up or coughing, you look good enough to me so – hop into the car!” Off we went. Then, 3 hours later the school called me – the poor kid had thrown up. All over his teacher’s shoes. My son is in college now but – I’m guessing I will never live that one down! at The Exam Room Door

I was at a work meeting recently. One meant to address physician “wellness”, but held ironically at my kids’ dinner and bedtime. We were given a stack of Post-it notes and asked to write down things that made us happy during our work days. I wrote:

  • laughing 6-month old babies
  • having time to get to know patients’ families
  • choosing stickers with my patients

The doctor next to me wrote:

  • no shows

Well, there is that. What doctor doesn’t dream of the occasional break in the schedule created by a patient not keeping their appointment?

One morning recently, I saw the name on my schedule of a patient that led me to spend the rest of the day hoping for a smile-inducing no show. When the patient arrived, I sighed a deep sigh but, then decided to test out some of the mindfulness-in-the-workplace practices I have spent the past few months learning. As I headed to the room, I thought to myself:

S for stop what you are doing (hand on doorknob, poised to enter into the room and

Take a breath. Stop thinking of the name on the schedule that brings you stress. Put aside the last phone call. Put aside worrying that the dog stuck at home alone might be eating the trash and the kids need rides to practice and that you need to be home on time tonight. Stop and

Observe how you feel. Yes, your jaw is, as usual, tense. Your leg hurts. Loosen those. Let go of the stress. Ask yourself what you can offer this family. What do they need from you? What can you bring to the exam room behind the door; what can you be open to? And then,

Proceed – open the door.

I have known this family that makes me hope for a no-show for many years and through several children. On that day though, somehow, we connected. I asked first how their ill father was feeling. I asked about their financial struggles. I asked how school was. Then I turned to the reason for the visit. It felt softer and easier to work together. We left with smiles and, for the first time in ages, they left without an antibiotic prescription.

I do not find this physician wellness, mindfulness stuff easy. All the deep breathing tends to send me off for a nap. But on that day, giving it a try worked well. I’ll be again.






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Full Spoons at Medicine X

I heard a few people talking about spoons on Friday morning at Stanford’s Medicine X conference . They were wondering why artist-in-residence Rachel Stork Stoltz, had asked us all to bring a spoon to the conference? After listening in a bit, I leaned over and tried to answer their questions. The spoon theory was created by Christine Miserandino and is a powerful way of explaining to a healthy person what it feels like to live with a chronic illness. You start the day with a finite amount of energy and as you move through the day you use quanta of energy (spoons) with even the smallest tasks of daily living. You count your spoons and may find you do not have enough spoons (energy) left to do what you want or need to that day because of the demands of your illness.

At its best moments Med X was a masterpiece of collaboration. It was a bringing together of patients, physicians, thought leaders and innovators to work together to discuss the future of medicine. Our recursive efforts mirrored and repeated each others’ in a way that built a powerful basis of understanding to move forward with.

Pamela Ressler opened her panel discussion on communicating the experience of illness in the digital age with a stunning quote from Susan Sontag:
Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.
Using an understanding of this commonality allowed us to enter into a dynamic dialog. I left the Med X space with more questions than answers. The questions are in themselves powerful motivators.
  • How will I recognize the daily efforts of patients in the days of their lives not in my office?
  • How will I be as caring as an old-school physician and as vital as a fully connected 2.0 MD.
  • How will I allow a space of communication about patient’s emotional challenges (as well as those physical)?
  • How will I shape my efforts to motivate health change through social media?
We did bring spoons to Med X and used them to create a sparkly, swirling tower of energy. We were each asked to think of what saps our energy and what refills our spoon count. I paused between lectures on Saturday and stood in the sunny afternoon decorating my spoon with wire and beads and copper. I tried to think as I worked not only of my own energy but of the more carefully counted energy of patients with chronic illness and hoped that they too felt a renewed spoon count from the connections forged at Med X.
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Rachel Stork Stoltz and our spoons
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MedX Day One – Going The Extra Mile

After this, the first day of Stanford’s  Medicine X conference, my mind is blown and my heart is full.

This word cloud of tweets today from @tmlfox analytics sums it all up well. BwyU7q0CYAAhFoo (1)“Patients” are at the center and are surrounded by “empathy”, “team”, “livestream” and “care. We see “relationships”, “mind” and “stories.” All are the spirit of MedX. All represent why I attend this amazing conference. There is the pure fun of the technology: tweeting, scanning our neighbor’s barcodes and using an app to request blanket deliveries. There are the people – each more inspiring than the next. The food is great and, have you met @therealzoechu?

At the end of the day though, none of that is really to the point. Instead, what matters is that I am left here pausing, quietly asking myself how I can be as caring a doctor as medical historian Barron Lerner’s physician father. He was a doctor of another generation. A generation of men faulted now for practicing paternalistic protection of their patients but praised for giving all to their work. They took call 24/7, they took every opportunity to reach out when needed, they went the extra mile.

In this era of technological involvement and focus, in this time of schedules and hurry, how do I go that extra mile? How do I pause and turn towards the person in front of me  take the opportunity to reach out and care?

Thanks @MedX.




Summertime And The Livin’ is Easy – If You Think Like a Kid!

Everyone loves summertime, right? Books, songs and movies speak poetically about the long, lazy days this time of year. We remember our own summers fondly. But I talk with many parents who have a less rosy view of summertime. Kids are home underfoot and rattling around complaining about being bored. Or, kids are home alone while parents go to work distracted by worry about the kids.

I experienced this worry one recent morning as I left my three to head to the office. I left them a hopeful note with chores for each (little brother: put away all the dishes and reload the washer, sister in the middle: mow the grass, big brother: sort the laundry). I reminded them of all the healthy leftovers in the fridge to munch on. In a feeble attempt to keep them away from too much screen time, I added reading suggestions. As I drove away I envisioned a Utopian day filled with cleaning, reading and sibling harmony. Instead by the end of the day I was reminded of Erma Bombeck’s humor:

Being a child at home alone in the summer is a high-risk occupation. If you call your mother at work thirteen times an hour, she can hurt you.

So what’s a parent to do? Throughout the school year, our kids learn about fitness and nutrition. They work their minds and bodies. How do we keep our kids active and healthy during the summertime? I find it helps me to think like a child; it helps to think back to what I enjoyed in the summer as a kid. Here are some ideas (inspired by my childhood memories of summertime) that my family has enjoyed this summer:

  1. Swing. The other evening, I was watching TV with my youngest child. In one scene, a character was swinging her child at the park. I remarked to my son that I missed swinging. He paused the show, looked at me and said “Let’s go!” So we did! Remember the floating feeling of swinging? Head to the park and try it with your kids.
  2. Play outdoor games. What games did you play as a kid? I needed to look up the rules to some but, we have found the old-fashioned ones are still a hit. Try kick the can or can of sardines. My favorite as a child was ghost in the graveyard. Can your kids teach you how to play flashlight tag?
  3. Grow. Kids love to grow a garden and we like to see them eat their veggies. It’s a match made in heaven that most parents can facilitate. Even in the smallest backyard you can grow some food. Try radishes first – they are fast and fun! In a city kitchen you can grow some sprouts for salads.
  4. Cook. Head to the kitchen to cook inspired by your garden harvest. It makes for a great chance to talk about what foods are healthy for us and which ones should be eaten in moderation. If you find that your garden produced too many zucchini, here’s a great recipe for zucchini bread. Or try these fun smoothies and let your kids choose what to throw in the blender.
  5. Fly. When I was a kid, my dad and I made a box kite once. It was an elaborate and fragile thing made of paper and balsa wood. This summer, my son and I tried this far easier version of a simple kite made of things you already have at home. Then we had fun for days flying it. Took a lot of running to get that kite up!
  6. Watch. After running that kite for a while, my son and I collapsed in the grass and lay there watching the clouds. As we did a rabbit, a scary big-jawed fish and a palm tree floated by.
  7. Create. There are endless art projects to enjoy in the summer. One we have had fun with was making mobiles. The kids and I read The Calder Game by Blue Balliett then looked up information about the artist Alexander Calder. Inspired by his art, we searched at the park for things to balance for our own mobiles.
  8. Imagine. Reminiscing about my childhood summer times inspired my son to imagine the future. He is building a time capsule; a box filled with tidbits from our time to bury for people to dig up one day in the future.
  9. Build. Take all the blankets stored for winter and let the kids use them to make a blanket fort. If it is hot outside make it under a table. Nice day? Tie them to a tree branch. Then sneak a few healthy snacks and books under the edge and let your kids relax.
  10. Hunt. Not for deer. Make your kids a scavenger hunt using a list of things found at the park or in your house or yard. Or better yet, have them make one for each other.

The summers of my memories were endless days of exploration and fun. I remember eating summer veggies from the garden and drinking lemonade. I roamed and read. I think I was bored but my mother had the wisdom to let that boredom be the opportunity for me to create my own fun. It is indeed wise to let our kids relax into their summertime to find their own adventures. It is also fun to join in and fly a kite or sit under a blanket fort with them!



Zucchini Hiding

It’s that time of year again. The time of year when I get sneaky.

I have a passion for cooking and a love of gardening. An interest in nutrition and, a love for my children. Combined, these had me convinced that if kids were given the chance to grow their own food in their backyard or patio garden they would eat just about anything they grew.

My garden space is small but full and in July it is full of zucchini. But, it turns out that zucchini is not my kids’ idea of good food. Even if they did grow it. Funny thing that I can’t remember this in May when I put in the seedlings.

So, every year, this time of year, I am forced to hide zucchini everywhere in order to use it up. I have the most fun sneaking the truly huge, two foot-long zucchinis (that seem to grow ignored under those big leaves) in my neighbor’s beds. I sneak over when they have headed out to walk the dog and place, like the tooth fairy but different, a big zucchini under their pillows. Hee, hee.

Then, I turn to cooking up the more manageable fruits. For dinner there is no better choice than the recipe found in Barbara Kingsolver’s book Animal, Vegetable, Mineral for Disappearing Zucchini Orzo. It is a perfect way to hide three large ones. Hee, hee, hee!

Then for breakfast I whip up zucchini bread from a recipe I have tuned and tweaked for the past 18 years of feeding children. It is a perfect way to thin the crop and a fabulous way to trick reluctant youngsters into eating their veggies.


3 eggs

1/2 cup canola oil

1 cup granulated sugar

1 teaspoon vanilla

2-3 cups grated zucchini (or a mix of zucchini, yellow summer squash and carrots)

1 cup white flour

1 cup whole wheat pastry flour)

2 teaspoons baking soda

1 teaspoon baking powder

1/2 teaspoon salt

1 teaspoon cinnamon

1 teaspoon cloves

1 cup chopped walnuts

Preheat oven to 350 degrees. Grease a 9 x 5 loaf pan.

Beat eggs, oil, sugar, vanilla until light. Mix in zucchini.

Whisk together dry ingredients then fold into wet. Stir in walnuts.

Pour into pan and cook for 1 hour and 15 minutes or until center springs back and tester comes out clean.

Cool for 10 min then turn onto cooling rack.

When asked, don’t tell them what the green flecks are just let them try it first!








I have learned a new trick. On a busy day of seeing patients it is easy to run from exam room to office desk and off to the next exam room at a frenzied pace. The charts, the orders even the patients can blur a bit. It is not a way to move through my day.

Now before entering the next exam room, I put my hand on the doorknob and pause. I take a moment to notice how I feel, take a deep breath and let it go. I let go of what ever might be distracting me from what is behind the door. Then I turn the handle and focus more fully on the person inside waiting to see me.

One day last week when I opened the door there was some fun waiting for me. A boy had a wart that needed freezing with liquid nitrogen. It is a simple procedure that he had done before and he and I settled in to chat while I worked. Also in the room was his much younger sister – maybe five years old. This girl was wearing a dress and holding a rose. She was smiling and excitedly hopping from foot to foot but – not saying a word obviously trying hard to be polite and wait for me to finish up.

Now, this clinic day was as busy a day as could be.  But when my wart treatment was done and the bouncy little sister finally got her turn to talk, I listened. She said:

Please freeze it.

And smash it!

And so we did. I dipped her rose in the liquid nitrogen and handed it to her. With great joyful enthusiasm she smashed that rose into tiny fragrant icy pieces!

Then with wide smiles we said goodbye. She and her brother got their stickers. I went on, placed my hand on the next door knob and fully focused, went to the next patient.


Media and Your Teen: Ask Them to Decide

The American Academy of Pediatrics has clear words for parents seeking advice about screen time limits for children. No screen time for kids under 2 and no more that 2 hours a day for kids over 2. Less is better and content matters.

While I find these guidelines challenging in my office and in my home, my mother would have had no trouble enforcing these guidelines with me – for most of my childhood we did not have a television. I remember mornings in junior high school as being rough. Not only those mornings too early, cold (N.Y. State in winter is COLD) but once I made it to school everyone around me was discussing last night’s episode of this or that show. I tried to look casual and preoccupied while they sounded so…. cool.

As a Pediatrician, I understand the social power that being up to date with the latest show, game  or video has. Being connected on each of the latest social media tools be they Instagram, Vine or Snapchat, matters on today’s Monday mornings.

However, I want my teens and my teen patients to turn off their screens more. I know that doing so will broaden their horizons and shrink their waistlines. They also on some level, get this. It is though, hard to translate advice and understanding into action. Teens especially do not like to accept rules made for them without their input and buy in. At my house I always begin change with a discussion around the dinner table. It is a perfect chance to ask and listen.
It is perhaps ironic that I found some words to inspire teens to turn off their screens from a recent episode of Grey’s Anatomy. They have just the right touch of inspirational simplicity that appeals to the Pinterest set:

Decide .

We are all going to die. We don’t get to decide where or when.

But we do get to decide how we are going to live. So do it.


Is this the life you want to live? Is this the person you want to love?

Is this the best you can be? Can you be stronger, kinder, more compassionate?


Breathe in, breathe out and decide.

When you put it this way, few kids would choose to spend their time in front of a screen. And definitely not the average of seven hours a day on entertainment media, including televisions, computers, phones and other electronic devices that our kids are currently spending. Tonight at dinner, ask your kids to Decide. And then come up with a plan together for media use in your home.

For ideas about how to decrease your family’s media use read this blog post by Corinn Cross, MD or see the AAP parent’s web page .


Hoofing it to School “Old-Style”

Research is mounting; the evidence is weighing in on the side of the health benefits of having kids walk or bike to school. This is termed active school transportation or, AST. The benefit to our children of getting to school in an active way is clear: increased aerobic activity leading to healthier, leaner bodies. There are additional benefits to our environment of fewer cars and to our neighborhoods of greater social cohesion.

Even given that actively moving to school would make our kids healthier more and more kids are driven by parents every day. In 1970 42% of kids actively got to school. Today? Closer to 13%. Changing these numbers can change our kid’s health.

When asked why their kids are not actively getting to school parent express concern about street safety, weather and distance. I understand these concerns. As a mom of three kids I have driven miles (in small ant-like circles around town) carting my kids to school, music and sports practices. However, my kids for the most part ride their bikes to school. Their elementary school is a 6.5 mile round trip which my youngest asked to do on his bike first in fourth grade. To calm my maternal concern I spent a good deal of time traveling with him to teach the ways of the roads and bike lanes and equipped him with a cell phone much earlier than his sibs were given one. Even now, a few years later I worry about his journey – is he safe? is it too long is he cold or too hot? For the most part though, I know that encouraging him to ride helps him: his body is stronger and he is more mature.

Deciding to chauffeur less can seem challenging. Here are some ideas to get you started:

  • Consider starting a neighborhood “walking school bus.” Neighbors and friends can take turns walking groups of children from “bus stops” to school.
  • If you plan to have your child start biking spend some time teaching them the ways of the road. Then bike with them until you are convinced they are ready to roll solo.
  • Some parents fear that their children may be intentionally harmed by others as the child walks to and from school. To help protect your child read my post on safety around strangers.

Above all rules, the one I have been strictest about is the helmet rule. When on anything with wheels they have to wear a well-fitting helmet. And it has to be strapped! To enforce this rule I used the “it takes a village” concept and have told all of my friends to notify me if they see one of my kids without a helmet. The kids know that they will be fined $25 dollars for the first time and that fine will be doubled with each “offense.” Years of safe bike riding had gone by when last spring I got a text from a friend saying she just saw my child without a helmet. I quickly fired of a text:

You owe me $25.

I immediately got the answer:

Wait Mom! My helmet is broken!

He biked in 5 minutes later looking worried and holding his helmet – in nearly two pieces. He had fallen and it had saved his brain. Fine revoked.

Active school transportation is an important step towards a healthier community of children. It is worth trying for your child! In a commentary written for the journal Pediatrics Dr.s Liu and Mendoza sum this all up well:

We recognize the many societal changes that have led to more students being driven to school. As parents, we empathize with families who worry about dangerous streets, distracted drivers, and challenging weather conditions that give pause to even letter carriers. When viewed through the eyes of child health, AST is an ‘old school’ form of physical activity that more children should adopt to make the daily trek to and from school.






Daily Tile

We are becoming increasingly aware that our children are in many cases, over scheduled, over stressed, over involved. As parents we feel overwhelmed by time pressures. The American Academy of Pediatrics has published several recent articles on how to help families with these challenges. One discussed the importance of play for kids themselves and also for us as parents. Play helps us maintain strong bonds with our kids.

As my kids are getting older I am increasingly listening to the little voice in my head telling me that they won’t be young for long. Now, when they ask to play or read I have begun dropping everything on my to-do list to jump up and join them. Rarer even than these requests for my time are pickup games of ball. Who just plays ball these days? Rarer still? Pickup games of kelpball on the beach at sunset.


Birthdays, Beets and Baby Carrots

I heard once that my influence over my kids’ final outcome ended when they turned five. By age five they had soaked up all the manners, values and habits they ever would from me. Now, on the occasion of my first child’s sixteenth birthday I find myself wondering if perhaps I have become dispensable.

His manners are for the most part lovely. Check. He is usually kind and generous. Check. He is clean and well dressed. Hmmm …clean – check. But do the pants around the buttocks count as well dressed? (before having kids there were several silly things I said in the category of “I’ll never”. “I’ll never let my boys wear their pants sagging” was one). He works hard in school – yes, and room to grow. He has commonsense. Um…. not always. This was demonstrated this week when he donated blood in the middle of lacrosse season and then wondered why he was so winded while running. Sigh. He understands the importance of physical fitness. Check! He understands the importance of good nutrition…. Uh oh. Wait, yes, I am sure he understands. This is where I see the wisdom of the five-year old rule.

As a mother there are household chores that I do happily, there are others that drive me slowly insane day after day. Making lunches leads the list of things making my hair go gray. One recent afternoon on the way to his lacrosse practice, my son asked if we could stop by his school locker to pick up something too big to carry on his bike. Indeed, the sack of old lunches filling his locker was big. And smelly. Turns out he wasn’t eating much of what I had packed. The carefully cut veggies, the fresh fruit, the whole grain bread all…moldy. Later that night I had one of those “Look out: Mom’s head is spinning!” moments that all children should see occasionally. Now I no longer make lunch, they do. I made some rules: each lunch must have a fruit, a veggie and some protein. It has worked well for the most part. Those were rules they knew by age five, right?

Yesterday my friend told me a story. She was at the grocery store during the high school lunch hour and happened to see our sons there. She quietly watched them go through the checkout aisle. My son had a 2 liter bottle of Mountain Dew. Her son, a family sized bag of Cheetos and their friend had a bag of Oreos. Well, I guess that explains the lunches in the locker. Why eat vegetables when you can eat your Cheetos with Mountain Dew? So, by age five he knew the food pyramid well enough to scold me when I crept up too high on it, but by age sixteen he is apparently very comfortable at its apex.

Now, I am left both looking back and hoping I taught him enough and gazing forward and hoping that the knowledge will resurface in time. His recent choice of a birthday dinner reflects this split in a way. He requested steak (“to replace the iron lost from donating blood this week so I can run better”), potatoes and … a vegetable. Great! Which one? Asparagus?

Ew, no.


Are you kidding Mom?

How about roasted broccoli?

No mom, just carrots.

The endless stream of baby carrots was part of what made me hate making lunches so much. Maybe if I show him this article about how eating beets can make you run significantly faster he’ll change his mind? ©

Veggie Pizza

In my post on eating dinner with my teens I owned up to sometimes cutting corners by ordering pizza for dinner. During a recent interview with the group Thriving Schools I also referred to surviving the work-kid juggle by ordering pizza. I was asked about the wisdom of these admissions. Perhaps @KPKiddoc should be putting a healthier face on her slice of life?

Let’s face it – pizza is everywhere. Hard to raise kids without pizza. Schools serve it often. Every soccer team party features pizza. And yes, tired working moms depend on it. Pizza can indeed be a nutritional nightmare. Given this and its ubiquitous nature, it is not surprising that I might be warned to appear more health conscious.

We want to feed our kids well. We are looking out for tips on how to do so; a google search of “is pizza healthy?” generates 132,000,000 responses. My answer is yes – it can be.  Here’s how:

Have just one or two pieces. One piece is more than enough for a small child; consider cutting it in half. Two pieces are sufficient, even for my athletic teens. At the dinner table discuss the concept of moderation with your kids.

Fill the rest of their plate with salad. 

Have a whole wheat crust. And definitely don’t “stuff” it.

Order or use less cheese. You can order extra cheese right? (don’t do it!) Turns out you can order less cheese also.

Skip the meat. Your kids will be happy with pizza – they don’t need to pepperoni to bribe them into eating it… just say no.

Add veggies. Same concept – kids like pizza enough that they usually will choke down some veggies with it. If not – that’s what the salad is for.

Skip the fast food restaurant version.

Make your own. Ok, not for a night when you are tired but – definitely a fun family project. Try this healthy recipe from 9-year-old Kayla Wayman of Montana.

Given that 93% of Americans eat pizza once a month, 3 billion pizzas are sold annually in the U.S. and 350 slices of pizza are eaten each second – it seems that our love affair with this meal is here to stay. Let’s just work to make it a healthier message for our kids.

In Napoli where love is king
When boy meets girl
Here’s what they sing

When the moon hits your eye
Like a big pizza pie, that’s amore

– Jack Brooks


Confessions of a Closet TV Diner

As we stood at my kitchen counter today my friend said

You ought to write about it. Makes you seem human, you know?

So in the spirit of self disclosure inspired by two recent articles by parents who admit their shortcomings, here I am doing the same. First John Sarrouf director of The Family Dinner Project, wrote about missing too many dinners with his family. Then fellow pediatrician Kathleen Berchelmann wrote about what happened when her daughter went to bed with an iPad.

Sometimes my kids and I eat dinner in front of the TV.

When I was a kid I watched very little TV. Except when I enjoyed summers with my grandparents. Then after spending the days outside, I spent the evenings watching TV. My grandmother was a well-educated, cultured Southern woman who believed in table manners and personal style (I spend a lot of time walking around with a book on my head for her.) So in retrospect, it surprises me that during those summer vacations we ate nearly every evening in front of the television. On a TV tray, with china and silver but while watching TV.

Hogan’s Heroes. Mash. Hee Haw (seriously.) The MacNeil/Lehrer Report. Lawrence Welk (they were my grandparents after all.) The Mary Tyler Moore Show. Watergate.

Was it wasted time? Dinners without conversation made therefore a loss? I think perhaps, not. Instead I remember that what we watched together united us around shared references. We had plenty to talk about after the shows were done.

So perhaps my friend was right when she told me to stop worrying. The occasional dinner in front of the television without attention to table manners and conversation won’t damage the kids.

As a pediatrician and a member of the American Academy of Pediatrics’ Council on Communications and Media I am passionate about helping parents navigate their families’ use of media in a healthy way. I support the AAP’s recommendations that we turn off our screens as much as possible – especially at the dinner table. Dinners eaten together are important to me. Conversation a priority.

However, parenting is a messy business and we are indeed human. Parents need to forgive themselves errors – be they missing meals, giving kids iPads or eating dinners in front of a screen. TV dinners are certainly not ideal but perhaps my kids will benefit from my bending the rules occasionally. Perhaps we will have some incredible dinner conversations about what we watched. Goodness knows, How I Met Your Mother provides loads of teachable moments.

Finish each day and be done with it. You have done what you could. Some blunders and absurdities no doubt crept in; forget them as soon as you can. Tomorrow is a new day. You shall begin it serenely and with too high a spirit to be encumbered with your old nonsense. -Ralph Waldo Emerson

Twenty Questions

Last week I tried something new. Something a bit out of my comfort zone and something I have long resisted doing. I enjoyed the experience largely because of its novelty; it felt good to stretch.

The real fun began though, when I started telling people what I had tried. The statement “You’ll never guess what I did on Wednesday” became an interesting litmus test for how my friends and family view me. You might try it with your circle.
Here are their answers:
“You went sky-diving?” Yeah, okay… that person obviously did not know me at all well.

“Rock-climbing?” Ditto.
“You rode a motorcycle?” Really, people?
“Yoga?” Hmmm…
“You got back on Rollerblades? No.
“Run?” Hey really, would that be so unusual?
“Shop?” Ew.
“Skip work?” Okay, that would be surprising.
“Add a day in to work?” Sadly but no, working extra would not shock.
And now, in upside down and backwards writing, the answer is:
It really did feel good to stretch.

Teens and Table Talk

Before kids and when they were very small, I used to fear the teen years. Visions of my sweet cuddling tots turned goth, rude teens hiding in their rooms with ear-buds in danced through my brain. Now, with 2, nearly three teens at home I no longer fear. Their reality is a thing of wonder to me. They are not rude. Quiet at times but, not rude. I have to pull out the ear buds all too often but, they do not sulk behind closed doors. And most reassuring, they are still quite cuddly – when they want to be.
Given this reassuring state, I can be taken aback when they momentarily act like “real” teens.
I have held family dinnertime sacred in my house. Even through change, upheaval and redefinition of family itself, dinners together come first. Last night at dinner I asked the kids why they thought dinners together were so important. My middle child said with a snarky tone, “because they keep us connected at the heart.” Her hands acted this out with fingers first intertwined and then in the shape of a heart. Eyes rolled. But then, thankfully there came a smile.
The evidence continues to pour in. Eating meals with family is good for kids.  In 2010 a study of nearly 9,000 4 year-old children published in the journal Pediatrics concluded (in part) that young children who regularly ate the evening meal as a family had a significantly lower prevalence of obesity. Other studies recently published in the journal Obesity have supported the idea that teenagers who eat with their family are less likely to be obese at baseline. Then last month yet another group of researchers published data showing that teens who eat with their families have higher well-being, lower depression and fewer risk-taking behaviors. More work has shown frequent family meals were significantly associated with a lower likelihood of adolescent alcohol and tobacco use. In the May 2010 issue of Journal of Health Psychology teens’ experience at the mealtimes was found to be connected with this decreased rate of substance use.
Looking at all of this evidence makes it very clear. We need to eat dinner with our kids for the sake of their health. We need to cultivate ways to make our dinnertime conversations meaningful, interesting, thought-provoking. Sure, some of the research shows a benefit to simply sitting around the table together but, you might as well have fun while you sit there. Around my table we have through the years talked about almost everything. Any topic is acceptable if brought up with good intention and true curiosity. Politics, sex, religion? We have covered them all. We have played games. I have been repeatedly accused of being a pain about their manners. There have been giggles, anger and tears. We rate the meals so I know whether to cook the recipes again. Lots of meals have been rejected. And instead of cooking, many pizzas have been ordered.
Now with so many sports teams, part-time jobs, extracurricular activities and social engagements that my head spins keeping it all straight, we don’t all sit together every night. But, whomever is at home sits and talks. Sometimes I wait up and eat with the late-after-practice arrivers. Sundays we all meet – even if other invitations have to be turned down. I’d like to think this commitment has paid off through the years.
My eldest can be a bit quiet. I generalize this into fitting his teen boy status – they all keep to them selves a bit don’t they? Once not too long ago, I challenged him on his laconic nature. I asked if he would talk to me when it really mattered? He stopped, looked at me and said yes. I asked why? How could I be sure? He explained that he knew I could handle talking about anything. After all, we do just that on any given Sunday around the table.

The e-patient Paradigm Shift

A few years back, I hurt my leg. Badly. So badly, I wasn’t walking well at all, was predicted to never run, ski, swim competitively or, do what had injured me – skate. The injury was dramatically sudden, painful and scary in ways I had never experienced. My first doctor was unsure exactly what I had done. The next ordered the right test but told me there was no repair. The next consultant agreed.

Then a friend stepped in to help. He lives in Switzerland but even from that distance, managed to turn the tide for me. How? By going online and searching for doctors and surgeries related to my injury and by finding a support group of people who also had my unusual injury. He emailed me the link to the support group and I responded:

Thanks but, I’m not that kind of patient.

Don’t be silly, he told me. So I clicked the link and found a world of education and support. In that moment of clicking, I became an “e-patient”

This new term, “e-patient”, is meant to describe a patient who is involved in their healthcare as an equal partner to their physicians. e-patients use electronic tools. They are empowered, educated and engaged. They see the importance in being equipped with the tools to help make decisions about their care. These tools can give e-patients access to medical records, education about their condition, or the support of groups of patients like them. e-patients are producing a culture shift in medicine.

This culture shift is especially visible in the area of breast cancer care. It is perhaps best illustrated with the story of one specific support group. Two friends who are breast cancer survivors teamed up with a breast surgeon from L.A. to start the support group #BCSM. It is held every Monday night as an hour-long “tweetchat” on Twitter. These three women explain:

While other physicians and academics debated how health care could even be discussed in social media and patients were warned to “be careful with research on the Internet”, two important facts didn’t budge. The Internet was not going anywhere. Neither was cancer. This year, some 290,000 women in the US alone will be told they have breast cancer. The need for #BCSM was clear. The project was on.

The mission of this impressive group is to support, educate and empower patients diagnosed with breast cancer. Patients meet and discuss their situation online to come out of the isolation that cancer diagnosis and treatment can create. Last Monday, 156 people actively participated and through their discussion, sent 2,724,048 impressions to their Twitter followers. Every week, expert physicians are invited to add “perspective and clarity” by discussing evidence-based recommendations and research with the group. The #BCSM support group’s mission has been accomplished through this inspiring model of weekly collaboration between physicians and patients. Both benefit.

This shifting paradigm is one we physicians may respond to with trepidation. We can feel irritated and challenged by patient involvement. And our patients do not respond well to our irritation. We are highly trained and this expertise gives us the ability to make informed decisions. However, our patients, especially those with chronic or unusual conditions, are also experts. They know about their own unique experience and through research can often know more about their specific diagnosis than their generalist physicians do. Patients can have an expertise to contribute to our decisions.

While I did not face the sort of life-threatening illness that catapults many into their role of e-patient, my experience taught me much. I see clearly that a well-educated patient has much to offer us. Seeking, supporting and trusting that input will serve us all well.


Fall and the Flu Vaccine: Believe.

I am tired. And, I’m not the only Pediatrician who is tired. It is fall, the traditional calm before the storm of sick patients that hits our offices every winter so why tired?
Because, visit after visit we hear parents tell us that they “Don’t believe in the flu vaccine.” Really?
  • In 1900 influenza was the leading cause of death.
  • In 1918 Influenza killed between 50-100 million people worldwide.
  • It is estimated by the WHO that in 2009 the H1N1 strain of influenza killed up to 575,400 people. 
So, I ask, what is there to “not believe in?”
The flu vaccine does not give you the flu.
Influenza is not a cold.
It is not the stomach flu
In 1918 every mother in town would have been beating down my office door to protect her child against influenza. They believed in its power. I have had influenza twice, once was H1N1 in 2009. I too believe in its power and yes, I get my flu shot and give the nasal vaccine to my three children every year.
As Seattle pediatrician Wendy Sue Swanson said:
In the medical community, we’ll work to undo myths around vaccine safety for the rest of our lives.
We may be tired but, it is a battle worth continuing.

All the Cool Cowboys Eat Yogurt (or, Nutritional Soundbite #3: limit drinks that taste sweet)

Two of my patients came into the office recently with their parent for check ups. I was a bit late coming in to see them so, started of with the all too familiar apology. Then we chatted about the heat and then summer books, movies, camps and camping. I asked what questions they had and, they asked if they needed shots (one did, one did not – always awkward to explain, that one!) All the while I realized I was stalling, dancing around the issue at hand.
Both children have weight problems. Technically speaking, their body mass indexes or, BMIs  are well out of the normal range or, in the range we physicians rather horribly term “obese.” They are both attractive, happy, smart and one is really quite funny. They like each other, they are respectful and fun. How on earth am I to find the words to tell them they are dangerously overweight without wounding their young confidence? Without alienating their parent?
I breathed in and began with the usual questions and followed with a display of their growth charts. It turned out the family had already been discussing change. They were walking each night. They were trying new veggies and thinking about serving sizes. I asked about what they thought I wanted them to drink?
And, what do you drink?
Juice! Apple and orange!
Ah, there was the change to focus on. I offered the rule of thumb that one 8 oz cup of juice a day has enough calories to cause a 15 lb weight gain over a year. That one usually works. But the parent looked at me and said with an exhale
But, it is just so hard to say no.
I get it. My 17 y/o son has a close friend that I adore. They have know each other since preschool days. I have watched this boy move from sandbox play to stellar sports play,  through cowboy costumes to awkward gangsta-style hats and now to be a rather stunning, clean cut young man. He is at my house often and when he arrives he walks straight through the door, around to the kitchen and opens the refrigerator. Spoon in one hand, he then heads to the boy-den in the garage with his bounty. It makes me happy every time. There is something in my refrigerator that he wanted? Cool.
We get such joy out of feeding our children. I cook well, my kids eat well and usually healthfully. My refrigerator staples are rather boring from a kids perspective. But, every now and then I will head off to the store and come home with some major treats. Watching the glee that comes as the kids root around and find these treats is fun. I feel, oddly as if I have done a good job. But after a bit, I get a bad taste in my mouth (and it is not from the chips :-) )
In fact, doing the right thing by our children means being a bit tough. Don’t buy the juice. Definitely skip the soda. Cut up the apples and put them in a central location. Skip the chips. You’ll never know what they learn to like. My friend the cowboy-gangsta-lacrosse star? He devours, container after container, case by case, high-protein, low sugar greek yogurts. And, go figure, all this time I thought I needed to bribe them with junk.

Love and “Non Sequitur” Defined (or, A Weekend Alone)

What does a working mother of three do when she finds herself home alone for three days? Well, true story, I can tell you the answer:

Bake, lots. Clean, prune and organize. And think. Lots.

Turns out though that I wasn’t completely alone. I had two rambunctious, trouble-generating puppies to keep me company.

Okay, I baked. First though, I started to clean the kitchen cabinets. As I cleaned I found bits and pieces of things that needed using up. The first was a jar of soy flour from… well, a while ago. So, I baked 8 dozen pumpkin muffins using the soy flour (there was more to use up than I thought.) Then I found a tube of almond paste left over from making stollen this Christmas so, I baked an almond pound cake. I found 3 half bags of chocolate chips. You guessed it – cookies.  Then a bag of golden raisins, a 1/2 box of currants, and some walnuts? Oatmeal cookies.

I thought about the meaning of love – after all, it was Valentines Day this week. Turns out, when you look on-line for a definition of love you may find out that

Love is patient, love is kind. It does not envy, it does not boast, it is not proud. It does not dishonor others, it is not self-seeking, it is not easily angered, it keeps no record of wrongs. Love does not delight in evil but rejoices with the truth. It always protects, always trusts, always hopes, always perseveres. 

The dogs certainly challenged this definition; I may not have been endlessly patient. I may have angered. I’m afraid I can list their wrongs (they got in the chicken coop – twice, vomited on the rug – once, peed on the rug – once, made a hole in the fence – once, escaped through their new hole in the fence – once, woke me at 530 – three times). And, I did boast a bit when a nice lady complimented my ability to walk two young labs at the same time (didn’t mention that I had run them in the fields for two hours before she saw us limping home.)

I watched TV and learned, from an episode of  “How I Met Your Mother”, that

opening yourself up to another person means opening yourself up to going a little insane

Okay, that definition of love I’ve got covered.


I looked up the meaning of the word non sequitur.

I did some laundry (I may have been alone but, I do have three kids.) Pruned the roses. Organized the freezer (to fit in all the baked goods) and then felt compelled to eat all the odd bits of frozen things there for breakfast, lunch and dinner. Read the NY Times all the way through. Looked at Twitter despite planning to take a “holiday” from social media. And there I found this definition of love:

Love, I’ve recently recognized, is that moment when you desperately need forgiveness from the one who inspires your best self for having just been, in some small, petty way, your base self.

I walked the dogs again. Made the beds. Cleaned a closet. Sorted through the CDs; listened to lots of Alexi Murdoch, Macy Gray and The Cure. And, spent several nice hours on the phone talking with a handsome man from Switzerland who has always inspired my best self. My Swiss friend asked me – It is hard to live alone isn’t it?

Its going to rain Tuesday.