The Pediatric Insider © 2009 Roy Benaroch, MD

For Dr. Patty de Urioste (1954-2009), a great pediatrician, partner, and  friend

1. Don’t rush. Even if you’re behind. Even if you’re waaaaay behind. Someone needs your time, and lunch (or dinner, or bedtime) can wait.
2. Have a plan. There is something that needs to be done next, even if the diagnosis is unclear. Decide what to do next, explain it, and do it. Parents need to know there is a plan.
3. Ask for help when you need it. No one knows everything. Call the specialist, call the ER, call the radiologist. Nag them if you have to, politely of course, until they tell you what you need to know. And remember it for next time.
4. Listen to your gut. If the kid looks sick, or the kid looks wrong, do what you need to do. Don’t trust the history or the labs or the x-rays more than you trust your own gut.
5. Help the patient. You might not have all the answers, and parents don’t expect a cure every time. Do what you can to help.
6. Treat your employees like family. Pay well, listen, and make your business a good place to work. They’ve got your back if you’ve got theirs.
7. Don’t miss an opportunity to learn. Every question is a chance to learn something new, and you never know when you’ll need that new tidbit again.
8. Eat lunch. Whatever happens, however late you are, you must eat. And use the bathroom, too.
9. Love books. Order them, buy them, smell them. You’ve seldom seen someone as happy and excited as Patty with a new load of medical textbooks.
10. Don’t complain to patients. They care about you, but they’re there for their own problems. Focus on them.
11. Listen. Someone is trying to tell you something.
12. Wake up early. There’s time to sleep… later. No one regrets not getting enough sleep. Many people regret things they never got to do.

The Pediatric Insider

© 2009 Roy Benaroch, MD

Analise is trying to get her daughter to continue drinking milk: “My daughter is 14 months old and will only drink milk from a bottle. We introduced a sippy cup at 9 months but made the mistake of only putting water in it. Now she associates the cup with water and the bottle with milk. We’re in the process of weaning her from the bottle but don’t know how to convince her to drink milk from a cup. Do you have any tips or is it just try, try again until she accepts it? Thanks for any behavioral insight or advice!”

First, let me get myself in trouble with the dairy council and moms everywhere by letting this secret out: there is no essential need for toddlers to drink milk. It’s a good source of protein and calcium, sure, but there are plenty of other good sources. Lots of children stop drinking milk, and many adults never touch the stuff. There’s no reason to consider milk something crucial for children to drink once they’re outside of the young baby years and able to take solids well.

At fourteen months, whether or not your child is willing to drink milk from a cup, you ought to stop using baby bottles. They’re bad for her teeth, and they’re preventing her from developing normal eating habits. Don’t worry that your child won’t get enough fluids—she’ll drink water, and she will not become dehydrated without milk.

Though milk isn’t essential, it’s handy and most children continue to drink it. There are, of course, tricks worth trying to get her to drink milk from a cup:

• Add a little milk to the water in a cup, and day-by-day start adding more milk and less water. In a few weeks, you can wean up to full strength milk. Do this gradually and maybe she won’t notice.
• Add something to the milk to make it extra tasty: chocolate syrup, or maybe a mashed-up, very soft banana. Little girls (and boys) deserve a little chocolate in their lives.
• Try a different sort of cup, like one with a straw—maybe even a crazy bendy cool straw.
• Make sure she sees you and dad drinking milk from a cup. You two can even use sippy cups for a little while. If parents don’t drink milk, children are far less likely to want it.
• If you’ve been using whole milk, give 2% or skim a try. Older advice did recommended whole milk, but that’s not necessary.
• Try a different sort of milk, like soy or almond milk. These provide similar amounts of protein and calcium as cow’s milk. Rice milk, on the other hand, is a low-protein beverage more similar to juice than milk—stay away from it if you’re looking for something with nutritional value for your children.

What to do during the transition? Don’t worry about it. There is no reason a child can’t go weeks or months or even years without milk. If your daughter gets the impression that milk is something very special and important, she’s less likely to touch the stuff—this is called “yanking your parents’ chain,” a skill that all children learn sooner or later. Don’t get caught up in the drama by letting her know you’re worried about this. Win the chain-yanking match by dropping your end.

If in the long run your daughter still won’t touch milk, you’ll need some other good calcium sources:

• Any other dairy: cottage cheese, yogurt, cheese, ice cream
• Calcium fortified juices
• Calcium supplements, like the little chocolate squares marketed for women as Viactive
• Non fat dry milk powder. Don’t mix this in water to try to drink it—bleach—but sprinkle it in casseroles, soups, eggs, sauces, that kind of thing. Once it mixes in it’s just about impossible to taste. Think of it as cheap calcium –n- protein powder.

Try some simple tricks to see if you can get your daughter back on milk, but remember there is no hurry here, and this is not a crucial or even a very important issue. Milk is easy and cheap, but there are many other nutritious things your daughter can take that can replace milk if she’s decided she just won’t drink it any more.

The Pediatric Insider

© 2009 Roy Benaroch, MD

Mark’s frustrated. His son has gone through several months when he seems to blink a lot—then it goes away, then it comes back later. It doesn’t seem to bother the boy. One doctor said it was allergies, and prescribed an eye drop; another one says it’s a compulsion, and that dad should ignore it. What’s going on here?

Most likely, he’s got a tic. Not a tick—that’s a blood sucking beetle-looking thing—but a tic, which is a quick, short involuntary muscle movement. The most common tics seen in kids are blinking, followed by throat clearing; sometimes kids have a little quick facial grimace or a neck-turn.

You’ve got the wiring for a tic, too. Let’s watch yours. Go ahead, stop blinking. I’ll wait here. Dum dee dah dum. Still not blinking, right? It’s getting hard….hard to not blink…have to concentrate…so, do any fishing lately? no? ….wait …no blinky….wait….arrrgh blink blink blink blink blink blink. Aaaaaaa. That’s better.

What happened? Believe me, your eyes didn’t dry out that quickly. So why did you feel an urge to blink?

That’s basically what a tic is. It’s an involuntary movement—you can’t put it off, you’ve just got to do it. If you don’t, it gets harder and harder to stop it…until…blink blink blink! Blinking, in all of us, is like a helpful tic, an automatic mechanism to keep your eyes healthy. But sometimes that mechanism causes excessive blinking, or other sorts of quick involuntary movements that can’t be suppressed.

About 1 in 20 of us has a tic, and tics usually start to develop in early childhood. Usually, the individual tic goes away after a few months. But children who’ve had a tic in the past are quite likely, even after several months or years, to once again develop a tic, often a different one.

Do not tell a person with a tic to stop it. If he tries, the tic will become harder and harder to resist, until it returns in a more exaggerated fashion. The best therapy? Don’t talk about it.

Tics do get worse with emotional upset, anxiety, or tiredness. They stop completely when you fall asleep. Many people blame incessant throat clearing on “allergies”—but oddly enough, when they sleep, there’s no need for throat clearing at all. You’d think lying down would just encourage a nice pool of mucus, wouldn’t you? So why is there no need to clear the throat during sleep? Most throat clearers aren’t allergic—they’ve got a tic. But their minds “invent” the feeling of phlegm and the allergy story. Amazing, the mind, what it will come up with.

Most children with tics have only one, and it goes away on its own after a few months. No treatment is needed. Rarely, children develop multiple complex motor and vocal tics, often associated with difficulty concentrating at school. This is Tourette’s Syndrome—more serious, but far more rare than an ordinary tic. If your child has multiple tics and especially if school is becoming a problem, see a pediatric neurologist. Medicines are almost never necessary for simple, non-bothersome tics, but for the rare child with more serious tic issues medication can be very helpful.