Pediatrics and Its Daily Spiels

L. Gregory Lawton, MD


December 20, 2017

The appointment schedule for a general pediatrician in the outpatient setting is peppered with routine or well-child exams. "Each age has its stage," as the mantra goes. The newborn visit seats me next to a bleary-eyed mother and a wide-eyed father, fixating on feeding schedules, bluish hands, or hiccups. Parents of 18-month-olds wonder about tantrums or "where she got that attitude." The routine 4-year-old visit is itself about routines: bedtime, mealtime, and preschool. Teen visits are uniform for their lack of uniformity—it's the ultimate mystery visit.

After 20 years of practicing general pediatrics, I also have my routines. We all have our way of knocking on the door, greeting the patient and the family, explaining the growth curve, asking about daily life, performing the exam, talking about vaccines, et cetera, et cetera, et cetera. We have developed spiels for nearly every occasion.

None of these phrases or "mini-didactics" was crafted originally on paper. They evolved over time after having a spontaneous birth. Shaped by the responses we received from patients/parents as we spoke them, they have become honed and concise, as efficient as they are edifying (at least that's what we all hope and try to tell ourselves).

Why do we use them? Because nearly every parent of a newborn will ask about "those red bumps on his back," and I like to tell them that "erythema toxicum, though it sounds like one of the forbidden spells from Harry Potter, is a common, nonscarring, benign rash that will cease to be an issue by 2 weeks of age." Bottom line: This spiel works because it's honest; addresses the needs of the parent; and is, I hope, memorable.

At 18 months, I am prompted, either by the parent or the progress note template, to introduce the concept of toilet training.

"Where are all the diapers and wipes located in your home?" I ask.

"In the living room and Cammy's bedroom," the parents answer.

"Why? Do you want her to get used to going to the living room or bedroom to use the bathroom?" I ask.

Pause. (Confused looks).

"When you go home, move all the diapers and wipes into the bathroom. This way, without you saying a word, every time Cammy soils herself, you will literally have to take her to the bathroom to change her. Four, five, six times a day, she will learn to associate the bathroom with a bathroom-worthy activity. Plus, you don't to need to tell her anything. There's no other place to change her. She learns the routine by the location.

"Brilliant," they say.

One of my favorite issues is the feeding one. The parents of the 3- or 4-year-old (or even older) picky eater are running around like so many waiters at a two-star Michelin restaurant. "Oh, I'm terribly sorry about the seared duck breast; would the gentleman prefer chicken fingers?" They are frustrated that mealtimes have devolved into an up-and-down affair where they are trying to enjoy a meal (say, pasta), but Luca only wants pizza—for every meal. They are tired, perhaps even angry. And they want help.

I start by looking at the growth curve again, to reassure myself that the child is not one meal away from being blown away by a strong breeze.

"So, are you feeling like you are short-order cooks?" I ask.

"Some days. Okay, most days," the parents answer.

"Here's what I suggest. One: No snacks or drinks 90 minutes before a meal. Hunger is the best sauce.* Two: Make the family meal, and make sure there is at least one thing Luca likes. Three: Set the meal out on serving dishes in the kitchen or dining room with empty plates in front of each person, including Luca. Four: Set a timer for 20 minutes and announce that when it goes off, the meal will be over. Five: Let each person serve themselves (with appropriate help). Eat. Talk about school and the day, and the weekend and friends. When the timer goes off, plates and food disappear."

"But what if he doesn't eat?" they ask.

"He's not going to be blown away by a strong breeze, and you'll probably offer him food at the next meal," I reply.

"But what if he's hungry?" they ask.

"Then he will learn that choosing not to eat has consequences. Don't protect him or deliver him from these consequences with a snack—even a healthy one. Mealtime is a special time when we sit together, in a special place. It is not snack time. It is not TV time. It is mealtime."

*Although it has been attributed to many writers throughout history, I first came across the saying "Hunger is the best sauce" when I read Cervantes. Sancho Panza, the portly counterpart to the lanky Don Quixote, was not a man known to miss a meal. His sage observation has become part of my (nearly daily) bits of pediatric advice to many a parent.


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