Food Strike!

A recent facebook question: Any articles out there about what to do when your child goes on an eating strike? My son, who's five (soon), has these occasionally, and he's already thin as a rail to begin with :)

My answer became much too long, as this is a very common concern and there are so many aspects, so it turned into this blog.

This question (very common) always reminds me of the Judy Blume book, Tales of a Fourth Grade Nothing.  (One of my favorite books growing up.)  The younger brother in the book, Fudge, refuses to eat.  After many failed trials of forcing food, and bribing, his Dad finally loses patience and says "eat it or wear it."  Needless to say, Fudge ends up with the bowl of cereal on his head and goes around for days saying "eat it or wear it!"

Food Strike!  This is a common concern of parents.  But kids are smart, they won't let themselves starve.

Of course there are some instances that are cause for concern.  Red Flags include kids who are sick, recurrently vomit or ruminate, seem dehydrated, have problems with food allergies, are very limited in foods over an extended time, experience swallowing problems or choking, or who are not following their growth curve.  Red flags are another topic entirely!  Work with your physician in these cases.

If hungry, he will eat.  Just don't let him fill up on things that aren't giving a nutritious balance. Even just milk all day can be harmful because it lacks many vitamins and minerals, so a little milk with other foods is better!

• Offer veggies, fruits, cheese, nuts, etc at scheduled snack times. 
• Limit pre-packaged foods and snacks.
• Limit drinks other than water and low calorie milks.  These fill kids up and don't offer balanced nutrition.
• Put only a small amount on his plate... it might be overwhelming to have a full plate.
• Turn off the tv.  Have a dinner conversation with the family.  This not only sets up healthy eating habits, but also healthy family dynamics. Teens who eat with their families are less likely to have risky behaviors!
• Set a good example!  Talk about how much you are enjoying the healthy foods at the table. (Not how healthy they are, but rather how good they taste.)
• Keep foods separate on the plate... they might eat one food if not touching another.
• Set a time for meals and stick to it.  If your child doesn't eat, still clear the table.  When they complain of being hungry, don't be condescending.  Simply say, "I know how you feel.  I'm hungry too when I don't eat.  Dinner is coming up soon. I'm sure you'll be ready!"  Don't offer filler foods. Don't yell.  Don't over-discuss.  Kids are smart, they'll pick up on the fact that they need to eat at meal time or be hungry.  (They won't starve to death!)
• Hide healthy foods in casseroles, sauces, etc.  I love my blender... the food processor was too much for me to clean, but my blender works just as well!  Many vegetables have little flavor, which makes it easy to "hide" them in things.

• I put a can of beets in with the spaghetti sauce --makes a cool color without changing the flavor.    

• I put carrots, spinach, or cabbage in my smoothies without changing the flavor.  Strawberries, bananas, kiwi, and other fruits are much more flavorful than many veggies and kids tend to like their tastes.  I just try to match color to hide the vegetable. 

•  Puree onions, carrots, zucchini, spinach, and other vegetables in recipes rather than chopping them... kids won't pick them out!  Chances are they won't even know they're there.

• Try foods in different forms: 

• frozen peas are crunchy-- maybe they don't like the squishy texture of cooked peas
• raw broccoli is much different in taste and texture than cooked broccoli
• many kids love cheese over vegetables or foods dunked in catsup or yogurt
• it is fun to eat with fingers for a change... let them get messy!
• try cutting things into pieces and serve with toothpicks
• make a kabob of fruit and cheese pieces... it's always more fun to eat off a stick! 
• cut sandwiches with a large cookie cutter for fun shapes
• use small cookie cutters for bite sized sandwiches or fruit pieces 

• Try not to use food as a reward. This can set up unhealthy eating habits.
• Don't reward for eating.  Most kids will get the intrinsic reward of satiety.  They don't need stickers or dessert for eating a meal.
• Praise small steps.  If kids try a new food (whether they like it or not) praise the fact that they tried!

Set your expectations realistically.  Don't expect kids to eat as much as infants/toddlers or teens/adults.  Calorie needs go down when not in growth spurts.  Just make the nutrition needs balance.  Don't worry as much about volume as variety of healthy foods!  Most kids don't need supplemental meals in a can (Pediasure and other brands) ~ they are getting the nutrition and calories they need, there is just an imbalance of perception of what they need.  I always prefer a healthy, active, thin child over a child who is overweight and not active (and often undernourished due to poor quality foods).

Vitamin supplement use and need is debated (except Vitamin D, which is recommended for all).  In general, I think it is a good idea to give a multivitamin with iron if kids aren't eating well.  Iron deficiency actually causes anorexia-- increasing the problem!   Just be sure to lock up vitamins as if they are medications, so kids don't accidentally ingest too much. 

Most kids grow well during their picky eating and food strike phases!  Just be patient and aware of any red flags that need to be evaluated.  If you are concerned, schedule an appointment to discuss foods, growth, nutrition, and concerns.  Bring a typical food log of foods and drinks (with approximate volumes) for at least one week.  We can either identify a concern and develop a plan of action, or reassure you that your child is normal!

Middle Man Payment Plan?

Healthcare billing is a very complex issue, mostly because people are familiar with purchasing things with money or credit in full disclosure of costs, not the complex system of insurance billing.  


People pay a lot for insurance, and then expect insurance to cover the cost of care, but they often do not realize the details of their contracts with insurance - AKA the Middle Man.  

Patient <--> Insurance <--> Doctor Office

This is  a long post, so bear with me... it is such an important but complex issue. I am only touching the surface here.  If you can't read the whole thing, at least hit the highlights at the bottom!

Typical purchase:  Buying a shirt. 

• I select my favorite store. 
• I look through the rack of shirts and pick one that is the right size and color.
• I look at the price tag and decide if I want it.
• Maybe I have a coupon or it's on sale - I can calculate the discount!  
• If it is the right cost and meets my needs, I make the purchase. I can choose cash, check, credit card.  Maybe I have a gift card! 
• If it isn't right for any reason, I keep shopping.

Healthcare purchase: Full of Unknown costs... making the decision to "purchase the product" much more difficult.  

Product? What product?

• "Product" is the expertise and knowledge of the healthcare professionals. 
• There is nothing to take home to show.  
• Time spent with the provider may or may not end up with a prescription or other identifiable thing that shows what the money was used for.  
• You might leave the office with as many (or more) questions because final diagnosis of a problem can be a process that takes time.
• You might disagree with the diagnosis or treatment given.  You don't have the option to choose another shirt. You already bought this one when you signed in.  You could buy another (2nd opinion) but you'd have to pay for both.  I hope you talk about these concerns at your visit... don't just worry that we "missed" something or did it wrong! 

Costs are becoming more important to the consumer as many insurance companies are putting more financial responsibility on their policy holders and covering less medical costs.  So it would be best if we let you know our fees and your payment amount before we see your child, right?  Well, there's a catch to that.  

The catch?  I don't know what your insurance contract requires of you, so it is impossible to accurately tell you what your real cost will be until after my office gets the insurance adjustment.  I don't know exactly what the insurance company will pay and what they'll discount ... my billing staff can make an educated guess based on past experience with a company, but it varies from case to case.

In this difficult economic time this places financial stress on families. I understand this and am happy to work with families on payment plans if they let me know their hardships, but often they simply yell that I billed it wrong. Because of contracts between my  office and the insurance company and the patient and the insurance company, there are many rules and laws regarding how to bill and collect payment.  


Back to Healthcare "purchase":

• Patient/consumer uses a service.
• Place of business (ie doctor's office) submits a bill based on well defined codes.  This bill doesn't go to the patient.  It goes to the Middle Man.
• Middle Man (insurance company) reviews the bill submitted.  
• Middle Man discounts each item to what they believe is a reasonable fee.  
• Middle Man pays the part of the adjusted fee that they are contracted to pay. 
• Middle Man sends us this information and we write off the discount they applied and bill the patient/consumer the difference.  
• We have provided a service and it is several weeks to months before any money is collected. Anyone in business knows the consequences of this timeline of money collection. 
• Payment collected from the doctor's office depends more on what the insurance company adjusts the bill to rather than the original bill itself. 
• Note: although the bill comes from us and is due to us, it is a result of your insurance plan/contract!  In general, the less expensive your plan for monthly health insurance, the more you are responsible to pay with each use.

Let's run through a couple scenarios of this Middle Man payment plan.


First scenario: Well visit plus additional concerns. A child is scheduled for a well visit but woke with a fever and cough.  He has an insurance company that requires a copay for each issue seen in the office.  We provide the care for a complete well visit (monitoring growth, development, nutrition, safety, reviewing vaccinations, etc) and bill for that service. We also ask further questions regarding this illness and symptoms and discuss management for the fever and cough.  Addressing and Documenting these issues (after all, the kid isn't well) is important.  When the bill is submitted to the Middle Man, the insurance company sees that the child is sick, so tells us to bill the family for a 2nd copay.  Our contract with this insurance company requires this, so we must bill to the family.  By law we must follow our legal contract.  To fail to do this is insurance fraud.  I'm not willing to go to jail to save a family a few bucks.  Sorry. I love my patients and want to help, but I don't want to have to go to jail for trying to do a good deed.


Second scenario: Screenings and tests sometimes, but not always covered. Another child is in the office for a 3 year old well visit and is due for a vision screening.  We know that most people either don't have vision coverage or their insurance only covers one vision test every 1-2 years.  The standard of care (ie what should be done if we want to provide the BEST care) is to do the vision test at this age.  This causes many possible scenarios, most of which equates to a headache for pediatricians:

• If a patient passes a vision screen done at our office and the insurance pays:  great. Rare, but great.
• If a patient's parent refuses the vision screen in our office (or fails to take the child to the specialist when we refer) because they feel the eyes are normal and don't want to pay, but later learn there was a problem that should have been addressed earlier for better outcome: parent is upset with us that we didn't insist on screening. The child also suffers from an undiagnosed vision problem.  
• If a patient passes a vision screen and insurance applies the charge to the deductible: the parent is upset at us for charging something "that wasn't needed. I knew the eyes were fine." (Note: we are the bad guy because the bill comes from us, despite the fact that it is their insurance company that chooses this payment method.)
• If a patient fails our vision screen and insurance pays us: parent is upset because we used up the once/year (or every other year) coverage, and now they pay out of pocket for the ophthalmologist.
• If patient fails our vision screen and insurance doesn't pay: parent is VERY upset because they must pay twice! (us and ophthalmologist) Why is this? Screenings by nature pick up some normals so they don't miss any abnormals. If a child fails at our office, they need to be seen by a specialist to confirm if there is or is not a problem.  Two visits by two providers with two fees.  Ugh!  

So... how many of these vision screening scenarios ended up with all happy?  ONLY ONE RARE CASE!

Please read your policies and ask questions to your insurance company before visiting the doctor so you know your financial responsibility.  Plan accordingly to save some money for healthcare needs.

One major issue we are seeing is described in scenario #1 above.  We follow the use of CPT codes as published by the American Medical Association. To bill both a sick and well visit on the same date of service, we add a Modifier -25 to identify separate preventive medicine service (well child exam) and a problem-oriented service (ear infection, hurt foot, earwax removal, etc) on the same date of service. This is the national standard, but not all insurance companies cover it the same.  Middle Man may tell us to charge the insured family a second co pay.  Why?  Because they want their members to pay their contracted portion of each visit.  Simply saving up multiple issues to be seen on the same visit day does not result in a person being less responsible for their portion of medical costs agreed to in a contract.  You are responsible for what your contract states.


Or maybe you simply have a high deductible plan.  You will be responsible for payments until you reach the magic number in your contract.  You have the benefit of lower monthly premiums, but expect to pay more each time you need medical care.


Another issue is labs.  Some insurance companies ONLY pay for labs done at their contracted lab. This means that quick Strep throat test we did gets charged to you.  Unfortunately we didn't know this from your insurance card.  Is it worth it to you for the convenience of knowing results right away to pay for the rapid strep, or would you prefer to wait for the lab to give culture results in a couple days? If this is important to you, call your insurance company.  Tell us before we do the test!


Billing codes separate out parts of services/product. Immunizations are a great example of this. There is the vaccine component, and there is an administration cost to cover costs associated with a vaccine:

• vaccine insurance -- they are expensive and need to be covered!
• temperature control of the refrigerator--did you know if the temp gets too high or low it alarms so our vaccine doesn't become ineffective? After hours one of us is automatically paged and we have to go in to see what is wrong?
• incidental supplies like syringes, needles, bandaids-- all the little costs add up!

Some insurance companies pay only the vaccine component, but not the administration fee. It goes toward the deductible.  Do you know how your plan works?

What does this all mean?

• We would like to provide the best care to our patients in a timely and economical manner, but we need your help identifying what you want done and not done due to costs before your visit. 

• If we address well and "not well" issues on the same day, it might mean a 2nd co pay or deductible for you to pay.  Some issues deserve a separate visit due to the nature of the concern.  

• We encourage you to do the recommended follow up labs and tests discussed at visits for the best medical care of your child.

• If your insurance company tells us to write off a portion of your bill, we do.  It is illegal to balance bill a patient.

• If your insurance company tells us to bill you for a service, we do.  It is illegal to write this portion off.   

• If you have a high deductible plan, save the money you save on premiums monthly in a special account for use when needed. 

• If you have any questions about your bill, please feel free to call our billing department to discuss. Please choose nice words with our staff. They are only the messenger!

Humility: the Anti-Bully

October is National Bullying Prevention Month, a topic that is important to me because it affects most of us at some point or another.  I will post information all month on our facebook page about bullying.  I don't want to repeat details of recognizing and stopping bullying -- there will be lots of great information posted, keep watching our wall!

I want to talk more about learning how to prevent bullying from a different perspective.  The slippery slope of when friendly banter or bragging turns into hurt feelings.  The way kids treat family members can reflect on how they will treat friends and classmates. The way kids are treated by family members also shapes their behaviors.

Bullying varies in severity and type.  We all recognize severe verbal bullying and physical bullying, but there are shades of grey. When is it bullying and when is it just kids being kids?

Bullying is when kids hurt other kids on purpose, but what if it isn't on purpose?  Kids still feel hurt.  How can you tell if it was with intent to hurt or just a blunder?

• My team is better than your team.  Bullying or just a friendly competitive spirit?
• I got an A on my test!  Pride or making another feel small without knowing it?
• You got your hair cut? (in that voice)  Surprise reaction -- or does hurting feelings mean bulling?

Kids don't always recognize when they say something hurtful. They haven't learned to always think before speaking or acting.  This doesn't make the action acceptable, but it offers a teaching moment.

• Tell them when you hear words that can be hurtful. Ask how they would feel if someone said that to them.  
• Discuss how the look on the friend's face lets you know something is wrong.  Talk to kids about how to understand when another person looks hurt or changes their mood suddenly  it might be due to what was said or done.  When they see face changes or moods fall or become angry, they need to quickly think back to what was said.  They can ask the friend if they said something wrong.  They should apologize if the friend's feelings were hurt, whether the friend admits hurt feelings or not.
• Teach kids to speak up for themselves when someone says something hurtful.  Until their friends learn to recognize what they say is hurtful, they need to be told.  A friend will stop.  Hopefully the friend will apologize, but maybe they haven't been taught that yet.  Teach your kids to accept apologies and offer forgiveness. 

A bully will keep doing the same behaviors even after the behavior has been called to their attention.  Bullies tend to pick on kids who have less self confidence, so build up your kids. Let them know they are loved.  Teach kids that it is okay to ask an adult for help.

I believe that teaching core values and showing a child love can help prevent bullying.  This is counter to many of societies goals.  It involves a tricky balance between building self esteem with praise without over-inflating the ego or demanding perfection.  Love kids for who they are, not what they do.

Bullies are self-indulgent and impatient. They try to feel better or inflate their self esteem by putting others down, but don't feel happiness.  They blame others or the system for problems.  They often feel unfulfilled and need more out of life but they don't know how to achieve these needs.  They probably don't even see that they are unfulfilled.

Kids who know that they shouldn't lie, cheat, and hurt others because it is wrong might think twice before intentionally hurting someone's feelings or spreading lies.  Young children must learn this.  We need to talk to them about how their words make others feel.  How would they feel if someone said that to them?

Don't tell them how they would feel.  Ask them, guide them.

I think humility is the anti-bully.  Humble people put others first and treat others with respect.  They are not weak and they are not step stools.  They have self confidence and inner strength, but are happy when others are happy.  They don't need to prove themselves to others.  Kids who put others first will be less likely to try to put others down to make themselves feel better.  A mistake should not break their whole self esteem because they know they are loved for who they are, not what they do.  They shouldn't have to defend themselves.  They can admit their mistakes and not lie to cover them up.

Do not confuse humility with humiliation. Humiliation is of course bullying and the opposite of being humble and helping others.  

The best way to teach humility is to be a humble example.  Serve others. Volunteer.  Give praise freely and unconditionally.  Show caring and respect to all.  Give credit where credit is due.  Accept responsibilty.  Ask for forgiveness when needed. Offer forgiveness to others.

Teach kids to give out praise often to others.  Who doesn't love it when others notice them? What can we say to people with genuine heart felt praise?  Think of ideas together and praise them when you see them hand out praise!  This builds confidence all around.  Confidence protects against bullying!

Teach kids how to respond truthfully without making others feel put down and without seeming over-confident.  (No one likes the kid who brags...)

• "You scored the most goals.  Great job!"  

Reply: "The whole team was great. I couldn't score if they didn't pass the ball."

or "Coach taught me a great move.  I couldn't do it without his help."

• "Wow! You got an A on the test.  I tried so hard and got a C."  

Reply: "The way the teacher explained it really made sense to me. I couldn't do it without good teaching."

or "I had to study really hard too.  Maybe we can quiz each other next time."

or "Math might be easier for me, but you are great with music!"

Teach kids to apologize when needed.  No one is perfect, and there is always a need to know when and how to apologize.  Words must sound sincere.   Don't allow kids to work around the situation or lie to get out of trouble.  Don't allow them to put blame on anyone or anything else.  

Teach kids they can only control what they say and do.  No one can control what another says or does.  How can they change their words or actions to change the outcome of a situation?  

Have you ever read one of those books that have multiple endings?  The ones that say things like, "If you want to go into the house, go to page 43. If you want to go to the park, go to page 46." 

Have kids pretend that their life is one of those books.  

Tell him to pick a time that someone's feelings were hurt, a fight started, or he got in trouble.  

Now have him change one thing he did or said.  Play out the rest of the situation.  

Ask: How would the other person respond to your new action? How does that change the end of the situation?   

This takes some practice, but we can all learn from this type of reflection.

Adults need to model these behaviors.  Kids can't learn humility just from being told. They must be shown these behaviors daily.    

Kids who know what to do if they see bullying behavior or feel bullied can help stop the cycle.  Many schools have anti-bullying programs in place.  

Does yours?  

Do you model anti-bulling values at home?

Too Little Sleep in Athletes

I am very concerned on many levels about late nights required for local sport programs from a parent perspective and as a pediatrician.

Many physical and emotional problems have been linked to sleep deprivation.  I see many kids who struggle in school and at home with behavior and learning problems that are directly related to loss of adequate sleep.  Poor sleep is also related to obesity, poor growth, depression, anxiety, poor school performance, and so many other issues.  Sleep is needed for release of growth hormone, which is needed for bone and muscle growth, muscle repair, fat burning, and learning.  Sleep loss leads to poor attention spans, inconsistent performance, decreased aerobic endurance, delayed response times, and increased illness, and will therefore affect their game!  There is increased risk of injury in these tired athletes.

You can argue that one late night a week will not have devastating consequences, but I disagree. We have all heard that consistent bedtimes are important for sound sleep.  Ironically sleep deprivation often leads to insomnia and more sleep problems. You cannot sleep "extra" to bank sleep hours.  Kids will often sleep in on weekends to attempt to catch up on the sleep hours missed during the week, but that means a week of struggles emotionally and physically.  It also gets their sleep routine off balance, which again contributes to poor sleep.

It is recommended to exercise at least 2-3 hours before bedtime because exercise is stimulating, making it difficult to fall asleep after exercise until the body temperature and metabolism return to normal.  Yet I find that many school aged kids have practices and games in the late evening into night hours.

School aged kids up to 12 years of age need 9-11 hrs of sleep per night to function adequately.  Practices and games late in the evening shortchange their night's rest by far too many hours.  Don't forget to consider that the time to settle down after the game is up to 3 hours. The following day they are likely to have problems at school.  An overtired child often has MORE problems getting to sleep, which affects the rest of the week.  These younger kids tend to have a lot of noticeable behavior and learning problems. Many are misdiagnosed with ADHD and treated with medication, when all they really need is better sleep. It is simply not acceptable to set them up for this failure.

As kids enter middle school they often need extra sleep due to puberty.  (Growth hormone is released during sleep.)  Unfortunately, school tends to start earlier and their game/practice times are often later, meaning they might be getting up just a few hours after they are falling to sleep.  Do we really want to affect their growth during these important years? 

No wonder many middle and high schoolers fall to sleep in class and struggle with falling grades, irritability, depression, and more.

Kids shouldn't have a hard time getting up in the morning.  If they are, it's a sign of not enough sleep!

I should also include coaches and parents in this, since we will be required to teach and transport these kids. Adults will fall short of their recommended 7-9 hrs of sleep, which affects mood, weight gain, and attentiveness.  This affects not only health, but also home and office life.  Can you wake up before your alarm?  If not, can you get to bed earlier?  That is a healthier choice than adding an extra cup of coffee or energy drink to your day.

We as parents and coaches want our kids to succeed in all areas of life. We want to give them the tools they need for this, which must include proper sleep.  Practice and game times on school nights must take into consideration the sleep requirements of these kids.  I do not want to be responsible for allowing  my child to be out late on school nights, therefore contributing to increased risk of poor school performance, behavior issues, immune deficiencies, depression, growth and obesity, and all the other known consequences of poor sleep. Once these issues surface it is too late to prevent them and the snowball effect begins!

The question: What can parents do?????

Got Milk? Cow, Coconut, Soy, or Almond?

A Facebook follower asked about how to choose a milk substitute recently. There is not a simple answer.

For many years it was easy:  The American Academy of Pediatrics recommended whole milk from 1 year to 2 years of age, then 2% until 4 years.  At 4 years it was recommended to switch to skim milk. If kids couldn't tolerate cow's milk they were given soy.

Then came questions about the estrogen like effects of soy and the problem that soy allergy is common in milk allergic kids.

The obesity rates climbing in kids has put into question whether whole milk is needed until 2 years and if lower fat milks should be given at younger ages.  The answer to this is probably not routinely, but toddlers who are overweight can benefit from a lower fat milk.

Grocery store shelves now offer not only whole, 2%, 1%, and skim cow milks (regular, hormone free and organic of each of these!) and soy milk, but they also sell lactose free milk (in several fat concentrations),  rice milk, almond milk, coconut milk, and goat milk.

How do you make the right choice for your child?  Below is a nice chart from MyHealthNewsDaily.com comparing calories, fat, protein, and calcium contents of various milks.  Taste is a very important consideration for the picky child.  If they don't like the taste, they will not drink it.  Even the textures of the milks can vary quite a bit and might require acclimation.  Food allergies and intolerances drive many of the choices.  Note: none of these are appropriate for infants under one year.  Breast milk or formula are the only healthy options for infants due to other nutrients needed in an infant's diet! 

Historically it has been felt that toddlers need more calories from milk, and should not regularly drink a low fat/low calorie milk.  Because of the rising obesity rates (even among toddlers and preschoolers) this recommendation is changing and kids can drink lower calorie products if their caloric intake from foods is sufficient.  Beware of high calories in milks like coconut milk, goat milk, rice, or soy milk.  They have nearly as many calories (or more!) than whole fat cow's milk.

One cup of coconut milk has over 50 grams of fat and over 460 calories!  A special treat: yes. A routine daily drink: no!  

(For comparison, a BK vanilla milkshake has 412 calories and 23 grams of fat in 227 grams (just 1/2 oz shy of a full cup).

Calcium levels vary widely in various milks and should be taken into consideration when choosing a milk for your child.  Other foods, such as calcium fortified orange juice, yogurt, tofu, leafy greens, cheese, and fortified cereals, can (and should) incorporate calcium into the diet.

Vitamin D is very difficult to get through diet alone and it is recommended that everyone take a Vitamin D supplement.  For more information, click here.

There is no consensus that organic milk offers any health benefit.  Due to it's high cost, it is prohibitive for many families to buy organic.  Hormone free milk is available for a mid-range cost without the potential (yet unproven) risks of hormones given to cows.  There isn't any nutritional benefit of the hormone free milk or organic milk compared to conventional milk, but if you are concerned about hormone exposure from milk, hormone free is less expensive than organic.


Lactose free milk: 160 calories, total fat 9g, protein 8 g, calcium 30%
Lactose free reduced fat milk: 130 calories, total fat 5g, protein 8 g, calcium 30%
Lactose free fat free milk: 80 calories, total fat 0g, protein 8g, calcium 30%
(Lactose milk nutrition facts based on one cup, from www.fatsecret.com)

Screen Free Week Reflections

I have been a fan of Screen Free Week since I heard about it.  Even before I heard of the official week, it was a popular negative consequence in our home.  

I used to enforce unofficial screen free weeks at our house regularly when I saw my kid's behaviors turn toward selfishness, fighting, and whininess.  Turning off the tv and video games help.  Maybe it's because the screen activities wind up their brains.  Maybe it's because it is "down" time and they need active time.  Maybe because I was guilty of using the tv as a babysitter so I could get my own things done, yet the kids needed time with me.  There are many more maybes, but all I know is that turning off the tv and video games seems to always help.  I get a bunch of complaints at the beginning of the week, but by the end of the week the kids are in a new habit of finding things to do without electronics.  It's fun. We all get along better.

This Screen Free Week I realized that it is harder than ever though.  Not for the kids, but for me.  I can never get off computers completely.  We use electronic records at my office.  I use the internet to search for information related to my job.  Those are allowable uses, since electronics for work and school are exceptions to turning off the screen.  Computers are simply a part of our life.

We are all relatively new to all the opportunities for wasting time on tv (remember when there were just a couple channels?) and internet offerings.  We are plugged in from our computers and our Smart Phones.  We get a lot of work done and learn information on these Screens.  When can we unplug? How do we learn to manage our time?

This week I was going to at least stay off Facebook, since that is mostly fun stuff that I share with patient families. Work related, yes.  Necessary, no.  I feel that by posting to Facebook it encourages others to look at Facebook.  Facebook is a huge time waster for many. (And yes, this is from someone who is totally addicted to facebook... I spend quite a bit of time searching around on it to scope great things to share!) A great reason to turn off the screen for a week!  

But then I need to reevaluate the "Necessary, no."  What is necessary?  I still had to look at Facebook to be sure the office page was not being abused with posts that were inappropriate.  Most things I post are not timely.  There are some recalls that are important, but not really imperative to share NOW.

But there were several things that happened in this one week that Social Media could really benefit.   Where do you draw the line of staying off Social Media and when does it become "work" so it is excluded?

We did post two things to our wall that did seem to meet the criteria of important and timely.  One was a request from the Health Department to spread the word about an outbreak.  Why is this important?  Because 8 people in Kansas have been sick and 2 have died.  Warn people: good.  But then to see it, people are checking their Facebook posts: bad.  Such a slippery slope!

The second post was about our own office's access.  We were not warned that our parking lot was to be resurfaced.  Staff arrived to work and found the whole thing blocked with no access to our main door (until we convinced them it was unacceptable during office hours).  Yikes!  How to spread the word quickly?  Yes, we can call the patients with appointments and tell them where to park, but what about walk ins?  Facebook is fast.  It can be helpful!  But we told people to stay away for the week.  Sigh.  Just can't win!

A third post that didn't end up getting posted because it is a bit hazier in importance and timeliness.  We have promised that when we open flu clinic appointments we will share on our website and Facebook page.  Of course we were able to secure a couple dates during this Free Week.  We posted to the website, since people always use that for health matters, not "fun".  We sent out an email to registered website users.  But we didn't post immediately to Facebook, again to encourage people to stay off Social Media for the week.  But Facebook isn't purely Social.  It is used to share information in a way that wasn't possible years ago.  (No worries for those of you who haven't signed up yet... there will be plenty of time to sign up!) 

Other posts that aren't timely were easy.  Save for later.  I am using a scheduling system that schedules posts, so I don't have to post daily.  That is helping manage my time on Facebook.  I still have to look daily to check on posts, but it does help with time management.


I think that is where the secret lies.
We all need to learn time management with the Screens.  What is important? What are time wasters?  Time wasters aren't always bad.  It can be great to vege in front of the tv after a long day and just relax without any bothers.  It is fun to catch up on what friends are up to on Social Media.  It can save time if you have exciting news and post once for all your friends and family to see (less personal than a phone call or visit, but faster!)


We need balance.
We need to make time for family, faith, exercise, healthy family meals, and sleep.  Cutting out those important things in life to waste more time in front of the screen simply is dangerous.

Kid's Weight is Weighing in my Mind

Reports of increasing obesity levels have been circulating for years on the news.  I see kids in my office regularly who are in the overweight or obese category and we all struggle how to treat this growing problem.  Excess weight in childhood is linked to many health issues such as high cholesterol, diabetes, metabolic syndrome, and it can trigger earlier puberty- leading to overall shorter adult height.  Not to mention the psychological and social implications of bullying, depression, eating disorders, and more.

Why is weight so much more of a problem now than it was years ago? As a child I did not have a perfect diet, yet I was not overweight because we spent most waking moments outside if we weren't in school. My mother packed a dessert in every lunch box.  We ate red meat most days.  We usually had white bread and butter on the table at dinner.  We drank 2% milk and I ate ice cream every night.  But we walked to school-- without a parent by the time I was in 1st grade (gasp!)  There were only a couple tv channels, and Saturday morning was the only time we could watch tv.  We were able to ride bikes, go to a wooded area, play on a nearby playground, dig in the dirt, you name it - we found something to make it fun!  Today's kids are shut up in the house after school watching one of many tv channels or playing video games. Even those who are shuttled to activities get overall less exercise because it is structured differently.  They ride in the car to practice or class, then sit and wait for things to start. They might sit or stand while others are getting instruction. Simply put: they don't get to do things at their own pace with their own creativity for as long as they want.

What to do???  On one hand kids need to learn to make healthy choices to maintain a healthy body weight for height, but on the other hand you don't want to focus so much on weight that they develop eating disorders.  I think this is possible if we focus on the word healthy, not weight.   Starting at school age I ask kids at every well visit if they think they are too heavy, too skinny, too short, or too tall.  If they have a concern, I follow up with something along the line of, "How would you change that?" I am often surprised by the answers, but I can use this very important information to guide how I approach their weight, height, and BMI.  We talk about where they are on the graph, and healthy ways to either stay in a good place or how to get to a better BMI.  I focus on 3 things we all need to be healthy (not healthy weight, but healthy):

1. Healthy eating
2. Exercise (with proper safety equipment- but that's another topic!)
3. Sleep (again, another topic entirely!)

Food is a part of our daily needs, but much more than that. It is a huge part of our lifestyle. We have special meals for celebrations but on a day to day basis it tends to be more repetitive. We all get into ruts of what our kids will eat, so that is what we prepare. The typical kid likes pizza, nuggets, fries, PB&J, burgers, mac and cheese, and a few other select meals.  If we are lucky our kids like one or two vegetables and some fruits.  We might even be able to sneak a whole grain bread in the mix.  If our family is busy we eat on the run-- often prepared foods that are low in nutrition, high in fat and calories, and things our kids think taste good (ie things we won't hear whining about).  We want our kids to be happy, and we don't want to hear they are hungry 30 minutes after the meal is over because they didn't like what was served and chose not to eat, so we tend to cave in and give them what they want.  We as parents need to learn to stop trying to make our kids happy for the moment, but healthy for a life time.

There is often a discrepancy between the child's BMI (body mass index) and the parent's perception of healthy.  The perception of calorie needs and actual calorie needs can be very mismatched.  I have seen a number of parents who worry that their toddler or child won't eat, so they encourage eating in a variety of ways:

• turn on the tv and feed the child while the child is distracted
• reward eating with dessert
• refuse to let the child leave the table until the plate is empty
• allow excessive milk "since at least it's healthy"
• allow snacking throughout the day
• legitimize that a "healthy" snack of goldfish is better than cookies

Any of these are problematic on several levels.  Kids don't learn to respond to their own hunger cues if they are forced to eat.  If offered a choice between a favorite low-nutrition/high fat food and a healthy meal that includes a vegetable, lean protein, whole grain, and low fat milk, which do you think any self-respecting kid would choose?  If they are only offered the healthy meal or no food at all, most kids will eventually eat because they are hungry. No kid will starve to death after 1-2 days of not eating.  They can, however, over time slowly kill themselves with unhealthy habits.  

So what does your child need to eat? Think of the calories used in your child's life and how many they really need.  Calorie needs are based on age, weight, activity level, growing patterns, and more.  

One of my personal pet peeves is the practice of giving treats during and after athletic games. It is not uncommon for kids to get a treat at half time and after every game. Most teams have a schedule of which parent will bring treats for after the game.  Do parents realize how damaging this can be?  

• A 50 pound child playing 15 minutes of basketball burns 39 calories.  Think about how many minutes your child actually plays in a game. Most do not play a full hour, which would burn 158 calories in that 50 pound child.
• A 50 pound child burns 23 calories playing 15 minutes of t-ball, softball, or baseball.  They burn 90 calories in an hour.
• A non-competitive 50 pound soccer player burns 34 calories in 15 min/135 per hour. A competitive player burns 51 calories in 15 min/ 203 in an hour.
• Find your own child's calories burned (must be at least 50 pounds) at CalorieLab.

Now consider those famous treats at games.  Many teams have a half time snack AND an after game treat.  Calories found on brand company websites or NutritionData:

• Typical flavored drinks or juice range 50-90 calories per 6 ounce serving. 
• Potato chips (1 ounce) 158 calories (A common bag size is 2 oz... which is 316 calories and has 1/3 of the child's DAILY recommended fat intake!)
• Fruit roll up (28g) 104 calories
• 1 medium chocolate chip cookie: 48 calories
• Orange slices (1 cup): 85 calories
• Grapes (1 cup): 62 calories
• Apple slices (1 cup): 65 calories

So...Let's say the kids get orange slices (a lot of calories but also good vitamin C, low in fat, and high in fiber) at half time, then a fruit drink and cookie after the game. That totals about 200 calories.  The typical 50 pound soccer player burned 135 calories in a one hour game. They took in more calories than they used.  And I chose the cookie, which has fewer calories than other options (we're not talking nutrition here) and only let them have one...

What's wrong with WATER?  And eating real food after the game.  As a family. Around the table.  That snack is likely to decrease appetite for the next meal, and it isn't needed.  And if they're hungry, they're more likely to eat the healthy foods on their plate.

There are many resources on the web to learn about healthy foods for both kids and parents. Rethink the way you look at how your family eats.


Simple suggestions:

• Offer a fruit and vegetable at every meal. Fill the plate with various colors!
• Picky kids? Hide the vegetable in sauces, offer dips of yogurt or cheese, let kids eat in fun new ways - like with a toothpick. Don't forget to lead by example and eat your veggies!
• Buy whole grains. 
• Choose lean proteins.
• Eat together as a family as often as possible.
• Turn off the tv during meals.
• Encourage the "taste a bite without a fight" rule for kids over 3 years. But don't force more than one bite.
• Don't buy foods and drinks with a lot of empty calories. Save them for special treats. If they aren't in the home, they can't be eaten!
• Drink water instead of juice, flavored drinks, or sodas.
• Choose low fat milk (1% or skim) after 4 years of age. (Whole milk from 1-2 years is okay for the normal weight toddler. 2% milk is okay for the normal weight 2-4 year old.  It is now acceptable for most kids to take in lesser milk fat than previously recommended.) 
• Limit portions on the plate to fist sized. Keep the serving platters off the table.
• Don't skip meals!
• Eat small healthy snacks between meals. Think of fruit, vegetable slices, cheese, and nuts for snacks.
• Don't forget to move every day and get enough sleep!