what's the deal with developmental milestones?

I've heard a bit of hating on the concept of developmental milestones lately. Many parents seem sort of derisive and indignant about the idea, insisting that "each child is an individual," "they all develop at their own pace," and "the doctor is just trying to scare you." Well, the first two are true, but I doubt the third one is (unless your doctor is a terrible person, and that's a whole other issue).

I think people misunderstand what developmental milestones are and what they aren't.

They aren't hard-and-fast deadlines that every child must reach at the exact age specified OR ELSE. For instance, rolling over is a "four month milestone." But some babies roll over at 3 months, and some at 6 months. That's generally okay. It's an estimate, an average.

They aren't a judgement on your child or your parenting. If your doctor expresses concern that your 15-month-old doesn't say any words yet, they're not saying that your child is dumb, or that you're a bad parent. They're not even saying-- and this is key-- that anything is necessarily wrong at all... which leads to my next point.

Developmental milestones aren't meant to be taken in isolation. If an 8-month-old baby isn't sitting up yet (typically a "six month milestone"), but everything else is totally fine-- he's babbling, putting things in his mouth, grabbing toys, scooting across the floor-- it's probably no big deal. It's just something to keep watching for and encouraging. But if he's not doing any of those things yet? That could be a sign that something's wrong.

And that leads to what developmental milestones actually are.

Developmental milestones are a group of guidelines, meant to be taken as a group, illustrating the rate at which the average child develops. The AVERAGE child-- which means that kids may hit some milestones earlier and some later. The milestones are meant to give parents and doctors and other caregivers an overall picture about how a child is doing in several areas of development (usually categorized as fine motor, gross motor, communication, problem solving, and personal/social).

So why do we need these specific milestone markers that stress parents out, if the individual markers don't matter and they're just meant to give an overall picture? Several reasons:

•    Parents may not realize their child is behind in a certain area, especially if they don't have a lot of prior experience with kids, because their child is their "normal."
•    Doctors only see the child briefly, intermittently, and under strange and sometimes scary (to the child) circumstances, so they're unlikely to really see the whole child as he/she is.
•    Studies have demonstrated over and over that kids who do have true delays are identified much earlier when objective milestone questionnaires/evaluations are used, rather than the parent/teacher/doctor/etc relying on their general impression.

It's also important to note that even if a child does have a true delay in some area, it doesn't necessarily mean there is some terrible scary underlying problem that will make their life super difficult. They would probably be fine eventually anyway. My oldest daughter, Faith, had speech delay as a toddler; at 17 months old she really didn't say any words at all. She didn't have any other delays. We got speech therapy through Early Intervention and by the time she was 2, her speech was normal for her age. Would it have normalized if we didn't get therapy? Probably, yeah-- though it probably would've happened later (and it was frustrating to her to be unable to communicate well). But we also know that, on average, outcomes are better if kids get treatment for whatever delay they have earlier rather than later. There's no benefit to waiting.

"Missing" a true delay, on the other hand, can be downright harmful. So if doctors express concern about a certain milestone, they're not trying to scare you. It's just one piece of evidence that they don't want to miss, because while one piece may not mean anything, enough pieces of evidence put together can. Imagine one of those old-fashioned balance scales, with one side being "concerning," and the other side "not concerning." If you have thirty pebbles in the "not concerning" side and move one to the "concerning" side... well, who cares. But if you move ten to the "concerning" side, well then the scale starts to tilt. And if you paid no attention to each individual pebble, you would never realize they were adding up.

I also see a lot of fear when it comes to diagnoses like developmental delay-- not just among parents, but among doctors too. Everyone is so hesitant to "label" a child with a diagnosis, and would prefer to just call him/her a "late bloomer" and "keep an eye on things." But what everyone forgets is that the label doesn't change the child. Whether or not Faith was given the diagnosis of "speech delay," she still wasn't talking. What the label does do is make the child eligible for services that can help. Even if the diagnosis is later found to be inaccurate, the only concrete thing that has changed is that the child was given the opportunity to have occupational therapy or classroom modifications or whatever. (Maybe parents are worried that the "label" will cause others to treat their child differently... but here's the kicker:  you don't have to tell anyone if you don't want to.)

So basically:

1- If you're concerned, don't let your doctor blow you off. (Really.)
2- If your doctor is concerned, don't blow him/her off either. It can't hurt to look into it.
3- Even if everything turns out to be fine-- and in most cases it will!-- it doesn't mean either one of you was wrong to be concerned.

pediatrician psa: three good articles

I used to do these on Tuesdays, but I'm low on blog post ideas, so time for a couple links!

INSIDER INFO AHEAD!!

First, this awesome answer to the question: How can I tell if my child has a cold or a sinus infection?

This is an important question because kids get colds ALL. THE. TIME. And there's really nothing to do to make a cold go away faster, which is frustrating for everyone. But if it's actually a sinus infection (much less common), then antibiotics might help. Click to find out how to tell the difference!

Second, on a related note, an excellent explanation for why pediatricians don't (or at least, aren't supposed to) recommend cough or cold medicines for kids. (Spoiler: it's because they don't work.)

The third one tackles a different topic, but an equally frustrating one (and not specific to pediatrics). Have you ever wondered why your doctor always keeps you waiting? Hint: it's not because he/she is on a Starbucks break, on the phone booking a lavish vacation, or just fundamentally lazy. The author of the article follows the typical day of a primary care physician, detailing exactly how things get so far behind.

And in case you read it and think, "Well, why not schedule people for longer appointments?" there are two large reasons. First, many physicians don't have any say in the length of their appointment slots, which are often predetermined by office administrators for maximum cost-effectiveness. And second, if appointments are longer, then fewer patients can be seen per day, making it harder to get an appointment with the doctor when you need it.

pediatrician psa: bullying

There's been a lot of media attention to bullying in recent years (and its modern form, cyber-bullying). But what exactly is bullying? Almost all kids are mean or tease others sometimes-- that doesn't make every child a bully!

Bullying is a specific form of one person exerting power over another by means of fear and intimidation. It's generally a pattern of behavior, rather than a single isolated incident, and it's usually done in view of other peers (which is part of the power play).

This is a great article explaining the differences among being rude, being mean, and being a bully. I thought it was a really clear explanation!  Bullying can be truly terrible, and it's great that there's increased awareness about it-- but some parents can go a little overboard!

Here's some information from the AAP (including what to do if your child is the bully):  Bullying - It's Not OK

And some more info about cyber-bullying specifically: Cyberbullying- Important Information For Parents

pediatrician psa: where's baby

As with most summers, there's been a lot of publicity lately about babies and toddlers who are accidentally locked and left in hot cars by their parents-- which is extremely dangerous and a huge tragedy all around.

See here for more info, but here's a clever Car Safety Checklist from kidsandcars.org.

Be safe! Look before you lock!

pediatrician psa: marijuana, childhood obesity, and firearm counseling

Wow, am I the worst blogger in the world, or what? I'm gonna be a bit lazy with the *cough*supposedtobe*cough* weekly PSA as I ease back in to posting regularly.

The American Psychological Association emphasizes that marijuana is not harmless, especially for adolescents and young adults whose brains are still developing. Over 1 in 20 high schoolers report smoking pot daily (!!!), so this is a major problem.

This is a helpful article outlining practical steps to take if you're worried about your child's weight.  Some key points:
- The focus should be on living a healthier life, not on achieving a specific weight.
- Make it a family affair, not singling out the child in question.
- Never mock your child's weight (or allow siblings to do so), even if you think it's just gentle teasing.
- Make it fun-- if you have to force your child to do it, it probably won't work.

There's been a recent ruling in Florida which threatens physician's ability to ask and counsel patients about firearm safety. The American Academy of Pediatrics soundly condemns this decision. Pediatricians are expected to ask and counsel about all kinds of safety issues-- car seats, walkers, pets, medications, window blinds, lead paint. It only makes sense to ask, "Is there a gun in the house? If so, make sure to store it locked and unloaded with the ammunition in a separate location for safety."

I'll try to stop being so lazy about posting!

pediatrician psa: look! vaccines work!

As always, research shows that vaccines do, in fact, decrease the incidence of disease.

Rotavirus vaccines led to steep drops in diarrhea illnesses in children.

Chickenpox vaccine has led to 90 percent decline in cases and hospitalizations. (Yes, some kids do have to get hospitalized for chickenpox. And some die.)

pediatrician psa: why i am not in favor of home births

When I hear a pregnant woman say she plans to give birth at home, my heart rate starts to go up-- not in anger, but in worry. During my training in pediatrics, I spent three months working in the NICU (Neonatal Intensive Care Unit), and more than once I saw the outcomes of home births that had gone horribly wrong. Healthy moms, healthy pregnancies-- but something happened and the baby needed something that couldn't be provided at home-- oxygen, medication, IV fluids, a blood transfusion. Some of them were "neurologically devastated" (basically the medical term for severely brain-damaged) as a result. Some died.

This is not to say that bad outcomes don't happen in hospital births, too-- of course they do. And it's not to say that healthy babies aren't sometimes born at home-- of course they are. But if even one baby born at home could have been saved by quicker access to medical intervention, that's serious, isn't it?

Yes, it's true that women's bodies are designed to go through labor and delivery-- "pregnancy isn't a disease," as they say-- but just because it's natural doesn't mean it can't go wrong. Too often, it does. (Even rarely is "too often," in my opinion.) Humans are pushing the limits of what's possible, biologically speaking. Compared to the size of women's birth canals, our babies' heads are HUGE to accommodate our large human brains. This is presumably the reason our babies are born so immature, compared to the rest of the mammals in the animal kingdom, who are often walking within hours of birth (aside from marsupials, who have a second gestational period in their mothers' pouches). If human babies developed and grew any more before birth, they simply wouldn't fit!

I think it's wonderful that women want a good and memorable birth experience-- it is a very meaningful event, something sadly trivialized in our modern culture... but the outcome-- the child that is the result-- is really what counts. I see so many similarities to women who get preoccupied with having the perfect wedding, when it's the marriage that really matters. Instead of bridezillas, we have mamazillas (birthzillas? laborzillas? you know what I mean). Women who have The Perfect Birth planned out and typed up, with no thought to the "what-ifs."

I often hear home-birth advocates cite the need to avoid unnecessary medical intervention. Of course we should avoid unnecessary medical intervention. But we should have ready access to possible necessary medical intervention-- which isn't always foreseeable beforehand. When I was in labor with my oldest daughter-- a totally healthy pregnancy-- her heart rate dropped suddenly and we were taken to emergency C-section. She was fine, but her blood-gas readings at birth showed that she had been getting dangerously low levels of oxygen in her blood for the short time before the C-section. If she had continued getting those low levels for however-much-longer labor would've lasted (hours? I was only dilated to 7cm at the time), she could have had permanent brain injury.

Clearly one anecdote isn't proof. But numerous studies have shown that, generally speaking, giving birth at home is related to an increased risk of bad outcomes for babies. (Note I said "increased risk." Obviously plenty of babies are born at home without any complication. Riding a bike without a helmet increases your risk of head injury but plenty of kids never wear helmets and are totally fine.) See here, here, and here. (Yes, there are some studies that show there is very little difference in outcomes. That's what meta-analyses-- such as in the third link-- are for. Here's an explanation of meta-analyses for the curious.)

Find an OB or midwife you can trust, who knows your preferences, but please please understand the medical reasons for something before you dismiss it. With few (unfortunate) exceptions, medical personnel aren't out to undermine your birth experience for selfish reasons. They just want you and your baby to be safe. And the safest place to give birth is in the hospital.

(If you do decide to give birth at home, please make it as safe for your baby as possible and follow the recommended guidelines for planned home births.)

pediatrician psa: the brat diet

Have you ever heard of the BRAT diet? It's a bland, low-fiber diet intended to be fed to children when they have diarrhea or other GI upset. BRAT stands for Bananas, Rice, Applesauce, and Toast.

Here's the thing, though (which even some doctors aren't aware of): the BRAT diet is no longer recommended. It's not that those foods are bad for kids with gastroenteritis, it's that eating only those foods is an unnecessary limitation on nutrition. In most cases, kids with diarrhea will do just fine eating a regular normal diet as tolerated. Babies should continue their regular breast milk or formula (NOT diluted, which can cause dangerous electrolyte imbalances).

There are a few caveats, though:

- Avoid liquids high in simple sugars (soda, juice, jello, etc) because they tend to make diarrhea worse-- the sugar pulls more water into the intestines.

- Avoid very greasy foods, because they can alter the time it takes for the body to move food through the GI tract.

- Sometimes, kids with GI illnesses can become temporarily "lactose intolerant"-- basically, because their intestines are irritated, they have trouble absorbing lactose. The lactose then stays in the intestines and (just like the simple sugars mentioned above) makes diarrhea worse, and can also make kids gassy and bloated. Most kids with diarrhea do just fine with continued dairy intake, but it's something to talk to your child's doctor about.

If the child doesn't feel like eating much when they're sick, that's okay. The most important thing is that they keep drinking. If the diarrhea is mild, they can generally drink whatever they usually drink and they'll be fine. If the diarrhea is more severe, though, they're losing a lot of electrolytes through their intestines, so it's important to replace those electrolytes to avoid imbalances. The best thing to drink in that case is an oral rehydration solution such as Pedialyte or Enfalyte (or an off-brand version). It's not recommended to mix your own homemade electrolyte solution unless you've been instructed to do so by your child's doctor.

Patients' parents often ask me if it's okay if their child drinks sports drinks like Gatorade or Powerade instead (they do taste better than Pedialyte). Well, that kind of depends. The reason those drinks taste better than Pedialyte is because they're pretty high in sugar, which (as mentioned above) can worsen diarrhea. Also, the electrolytes in Gatorade are designed to replace the ones you lose in sweat, not the ones you lose in diarrhea, so they don't have as much sodium or potassium. But if your child's diarrhea is mild, it's probably okay to drink Gatorade. It's somewhat better than juice or soda.

Electrolyte Composition (based on what I could Google):
Per liter, Pedialyte has:
45mEq sodium, 20mEq potassium, 25gm sugar
Per liter, Gatorade has:
19mEq sodium, 3.25mEq potassium, 58gm sugar
Per liter, apple juice has:
1.3mEq sodium, 27mEq potassium, 100gm sugar

I also get asked about drinking plain water. Again-- if the diarrhea is mild, your child is eating, and they're not especially dehydrated, then water is great. But if the diarrhea is severe or your child is dehydrated, then drinking plain water can lead to dangerous electrolyte imbalances. These cases are when it's most important to drink an oral rehydration solution (and to make an appointment with the doctor!). This is especially true for babies-- if they're refusing formula or breast milk, or if you want to add extra hydration, it's NOT okay to give them plain water. Babies have immature kidneys which aren't as good at balancing the body's electrolytes and water, so babies are especially prone to severe electrolyte imbalances. It IS okay to give babies an oral rehydration solution such as Pedialyte.

For more information, see:
HealthyChildren.org: Diarrhea
KidsHealth.org: Diarrhea

For more detailed, clinician-directed information, see:
The Management of Acute Diarrhea in Children
Practice Parameter: The Management of Acute Gastroenteritis in Young Children

(Legal disclaimer: This information is intended only to provide general information and is not a replacement for medical evaluation, advice, diagnosis, or treatment by your child's doctor. I am a real pediatrician, but I'm not your pediatrician.)

pediatrician psa: top 5 foods parents think are healthy for kids but aren't

1. Juice. The juice companies have got us all fooled. Their commercials would have us believe juice is packed with nutrition and is "part of this balanced breakfast!" At worst, juice is little more than corn syrup and water with added flavoring-- basically, uncarbonated soda. (I'm looking at you, CapriSun and SunnyD.) At best, 100% juice may provide some vitamins, but it also provides lots of mostly empty calories that don't fill kids up-- they'd be better off eating fruit and drinking water. Because juice provides all the sugar of fruit but none of the fiber, it tends to cause watery bowel movements (contributing to a phenomenon known as "toddler's diarrhea").

2. Fruit snacks. See above-- same song, different verse. Sticky fruit snacks have the added benefit of getting stuck in kids' teeth and causing cavities. Give them berries instead (or dried fruit -- but see below).

3. Granola bars. These seem like they should be SUPER HEALTHY-- and okay, they're probably better than chips or cookies. But they have a LOT of added sugar, often in corn syrup form. And many granola bars have even more sticky-sweet extras in the form of chocolate chips, M&Ms, or even marshmallows. See also: trail mix.

4. Cereal. Sure, whole grain cereal with skim milk and no added sugar is pretty healthy. But switch it to a sugar-coated, refined-flour cereal (with marshmallows!) and it turns into junk food.

5. Dried fruit. Okay, this is actually healthy in most circumstances-- dried fruit is full of iron and fiber and other good things. But for kids who are overweight, dried fruit can be a hidden danger, because it's a more calorically-dense version of its fresh fruit counterpart. Think about it this way: no one would sit down and eat five plums, but you could easily eat five prunes. Twenty grapes would be a reasonably filling snack, while twenty raisins wouldn't be much more than a mouthful. Keep in mind, too, that some dried fruits (like banana chips) are coated in added sugar. (Also, most dried fruit tends to be quite sticky, which isn't so good for the teeth, just like fruit snacks.)

Check out the AAP's list of healthy snacks for kids!

(Legal disclaimer: This information is intended only to provide general information and is not a replacement for medical evaluation, advice, diagnosis, or treatment by your child's doctor. I am a real pediatrician, but I'm not your pediatrician.)