Tag Archives: Medicine

From the desk of Doc Smo: Pediatric Practice, the New Frontier (article)

I get a lot of reading material each week, way more than I can possibly digest with a full time job and a cutting edge blog to run. On Sunday, I received a newsletter from the Center for Disease Control with recent information that they have collected and published. I also get various pediatric new journals, including the journal Pediatrics, as part of my membership to the Academy of Pediatrics. While diving into these publications this week, I was struck by the number of articles that revolve around mental health issues. I went into the practice of pediatrics because I really enjoyed the practice of infectious disease. Pediatrics was an infectious disease specialty when I signed up for duty. Not any more; it seems to be evolving into a mental health specialty. Let me give you a flavor of some of the information that is coming at pediatricians these days:

Pediatrics, November 2011
“Media, Profanity, and Aggression”
“‘Action signs’ for Child Behavioral Health Problems”
“Shyness vs. social phobia”
“School Nurse Treatment of Adolescent Smoking”
“Correlates of Sedentary Behavior in Preschool Children”
“ADHD: Clinical Practice Guideline”
“Media Use by Children Younger than Two Years of Age”

The Mortality and Morbidity Newsletter from the CDC, January 2012
“Quick Stats- Depression in the population divided by age”

Pediatric News, December 2011
“Don’t Let Comorbidities Keep Obese Child on the Couch”
“15 Minute Interview for Serious Mental Disorders”
“Teen Behavior Involving Sexting Varies Widely”

The shift in pediatric practice from infectious disease to a mental health is undeniable. Fortunately, I feel that I am much better equipped to advise families with regards to behavioral issues now that I have 30 years of pediatric experience under my belt. Those families that I tried to help 30 years ago didn’t get as much bang for their buck. We were simply not trained or prepared to help families with behavioral problems, let alone families encountering true mental illness. If things keep going in the direction that I am seeing, the next generation of pediatricians better get ready for an ever-increasing amount of childhood anxiety, depression, behavioral problems, developmental disorders, and autism. Hopefully they will up to the challenge.

Tincture of Time (Pedcast)

In this week’s post, my discussion centers more on philosophy than physiology. Primary care physicians know that most human sickness, especially in children, will get better without treatment. Pediatricians are constantly weighing the potential benefits of a particular treatment against its potential harm. Most of the time they get it right, but as we all know, sometimes the treatment turns out to be worse than the disease. Watchful waiting with a tincture of time may be all that the child needs. Knowing when to intervene and when it is best simply to observe is the art of medicine.



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From the desk of Doc Smo: A Constipation Conversation (Article)

How many ways can constipated children come to the doctor?
I am totally amazed at the myriad of presentations that constipated children present to their doctors. I remember listening to MANY complex lectures in medical school and residency about recurrent abdominal pain and trying desperately to memorize the LONG list of conditions that present as recurrent abdominal pain in children. After all these years of clinical practice, common sense has finally taken precedence. Hold onto your seats for this DocSmo pearl: “Common things are uncommonly common.” In other words, don’t look for exotic illness when, most likely, everyday maladies are probably at work. Humans have two “common” reasons their stomachs hurt:

1. A lower intestine that is not completely emptying (Constipation)
2. An overly acidic stomach that doesn’t empty well and may actually reflux (send contents backwards) into the esophagus.

Let’s take a moment to talk about the first cause, constipation. Little kids—and even big ones—sometimes find pooping unpleasant. At some level they avoid it, and it catches up with them. When it does, they come to the doctor complaining of cramping pain (hollow organ trying to empty), feeling sick after eating (nowhere for food to go from the stomach), gas (excess fermentation in the colon), burping (slow gastric emptying), back pain (referred pain), vomiting (no room in the Inn), bloating, leaking stool, rectal pain, prolapse of the rectum… and the list continues. I am sure that another 30 years will bring many new variations on the same theme.

I really think we may have been better off when we lived outdoors, pooping wherever and whenever. I doubt children growing up in those conditions ever had stomachaches for the reasons we do now. Everything has to be so perfect for our children. They need to poop at the right time (when an adult says it’s ok), only in “approved” places, and quickly and cleanly: the so called Demand Poop. No wonder all the fuss!


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The Lunchroom Lowdown: Bathroom Boot Camp (Article)

I was telling my partners about Bathroom Boot Camp at lunch last week. The topic of potty training comes up regularly for pediatricians, and they were happy to share their experience for this blog. I posed the question, “What have you found are important things for families to remember when training and maintaining continence in their children?” Their answers were very informative. Here is a glimpse:

Dr. Monica Miller, one of my young “GenX” partners, felt that reward and a positive attitude are important. Parents need to set the correct ambiance and mood. She feels that the bathroom experience should be slow, not rushed. She also emphasizes highlighting success. She recommends a “Potty Parade” after each success: “Let’s celebrate! The toilet success is so important that we need to have a party!” Her approach emphasizes patience, praise, and fun. Dr. Miller thinks that the most difficult children to train are those who are very intelligent or those who have difficulty adjusting to uncomfortable sensory experiences.


Dr. John Plonk, on the other hand, is one of the older doctors (mid fifties) that I work with. He is definitely a boomer. He grew up on a farm with days full of hard farm labor. His young life was dominated by work, dirt, and animals, so his attitude is “let’s get the job done.” He suggests letting children observe animals around them, learning through imitation. “Everyone pees and poops,” he says, “even animals. Children just need to observe what is happening around them and do as they do.” Being outside most of the day facilitates training since the deeds can be done anywhere; this method encourages children to take charge and be the masters of their own domains. Also, it’s hard to mess up too badly outside. Dr. Plonk recommends celebrating success with what he calls Flushing Fiestas: “Kids love to flush toilets, so make that their reward for cooperation when indoors.” Dr. Plonk also feels that a diet rich in “P” fruits promotes success: pears, plums, peaches, pomegranates, and popcorn. A great suggestion, and easy to remember. He recommends avoiding bananas and limiting dairy and cheese during the training process, for obvious reasons.


Dr. Kimberly Riley“If your stomach hurts, you need to poop, it’s that simple.” No wimpy poop for her patients, they need good volume. To achieve this, she emphasizes the relaxed bathroom, much like Dr. Miller. She recommends taking advantage of the gastro-colic reflex, the reflex that empties your child’s colon just after eating. “Routine toilet sitting is important, and don’t rush.” She encourages the parents of her patients to allow videogame use only in the bathroom. Dr. Riley declares, “Finally a good use for a video game!” Amen. Dr. Riley also points out that the school setting is particularly bad for regularity for many children since they do not have free access or adequate time in the bathroom while at school. Be aware of this fact as a parent, and make the necessary adjustments when possible. Dr. Riley feels that the strong willed child is the most difficult to train.

I hope some of these insights are helpful to families as they deal with the often-difficult task of potty training. I think the main thing to remember is that all normal children eventually master the entire bathroom experience. Be patient and don’t go negative. Remember, your child is the only one who can actually control their sphincters, both rectal and urinary; to have ultimate success, your child needs to take control. I recommend creating an environment that cherishes success and encourages independence. Good luck.


For a complete list of this week’s potty content, check out the topic of the week!


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