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Do babies need schedules?

Posted by Dr. Claire McCarthy July 29, 2012 11:31 AM

It's a question I'm often asked by parents in my practice: does my baby need to be on a schedule?

And as with so much in medicine and parenting, the answer is a resounding...maybe.

Babies do have and need schedules of sorts. They need to eat regularly (usually around every 2-4 hours, depending on whether they are breast-or formula-fed) and sleep (around 16-18 hours a day sometimes). In between and around those, they need diaper changes. And when they are awake and alert, it's good to interact with them--and get in some tummy time.

But do all those things need to happen at the same time every day? Probably not, with some caveats. 

There are definitely upsides to schedules--they give a certain order and predictability to life and can make it easier to plan your day (those baby nap times can be pretty darn crucial if you want to get anything done at all!). And there are some babies--and some parents--that really do need that predictability; they get very cranky without it.

There are downsides, though. I've seen families become slaves to schedules. They miss out on things they might like to do, and people they might like to see, because they need to be home for a feeding or a nap time. It can leave parents feeling constrained and isolated. And when something happens that throws the schedule off--like an appointment that runs late or an unexpected plumbing problem--it can be very stressful.
There are also some, well, realities to take into account. It's not so hard to make a schedule when you have one child and either no job or a very predictable job and childcare arrangement. When you throw another kid into the mix--especially when there are school drop-offs and pickups and activities involved--or when your job has variable hours or your childcare is different from day to day, schedules can become really challenging.

My husband and I are raising five kids. Poor Liam, our youngest, had no hope of having a set schedule. Sometimes naps were catnaps and meals were divided up into snacks. There were long days at swim meets or marching band competitions when he was toted around in a sling for hours. Some days went well, some less well. But he survived just fine.
Total chaos isn't good for anyone, and being a slave to a schedule isn't either. Somewhere in the middle is best. Where you fall in that middle is going to depend on your particular family situation, as well as your baby's personality (and yours).

I do think that it's good to build some routine into your day. It's helpful to you, and having some predictable routines is good for kids mentally and physically. Personally, I like the idea of morning and nighttime routines. 

In the morning, it's good to build in some snuggling, a good breakfast, and regular getting dressed and organized routines; having a good start to the day makes a big difference and will make it easier for going to childcare or when your child starts school. And at night, I love family dinner, a bath with some playtime, and some more snuggling (with books, once baby is 6 months old or so) with a consistent bedtime. That also sets the stage for healthy habits as your child grows--and builds in rituals of togetherness.

But in between...I vote for flexibility. Yes, you need to be sure your baby eats and sleeps enough. But give yourself some wiggle room. Don't turn down an invitation or give up a chance for something you'd love to do because it would get in the way of a nap or meal. It's good for your baby to learn to nap in a stroller or sling or in the car--and meals can be portable. If you're happy, Baby is likely to be happy--and especially in that second half of the first year, babies often really enjoy seeing and doing new things. 

The thing is, the best moments in life are often unscheduled. It all goes by so fast. Enjoy it.

To really help kids, don't mind your own business

Posted by Dr. Claire McCarthy July 29, 2012 07:38 AM
We've all been there. 

We've been in the grocery store, or at the park or the mall or the schoolyard, and seen a parent say something to their child that made us wince. Maybe it was an insult. Maybe it was a threat. Maybe it wasn't what they said, but something about the way they ignored the child. 

And we've thought: should I say or do something? After all, we tell ourselves, they aren't hitting them or anything. Maybe we should mind our own business.

Here's what I think: we should say or do something. It could make all the difference for that child.

The American Academy of Pediatrics released a clinical report this week in the journal Pediatrics entitled "Psychological Maltreatment." In it, they talk about how children who are psychologically or emotionally maltreated--which can include things like ridiculing, insulting, terrorizing, isolating, ignoring or corrupting--are at risk for serious emotional problems. Some of these problems, such as aggression, antisocial behavior or mental illness, can be lifelong. It's especially bad when children are maltreated in the first three years of life, because the brain is still literally developing and making connections. Without nurturing, those connections can go permanently wrong.

There are a couple of important caveats, though, when it comes to intervening.

First, you want to do it in a helpful way. Saying something like, "Don't talk to your kid like that, you jerk," may make you feel better, and may even be a wake-up call to the parent--but it's more likely that it will make the parent angry and defensive and not be helpful. If you see something egregious going on you obviously need to react--you might even need to call the Department of Children and Families if you think abuse or neglect is going on (which you can do anonymously). But in most cases, a better approach is a more friendly and supportive one. 

"Parenthood is so hard sometimes, isn't it?" you might say as you offer some concrete help, like holding the crying baby so the parent can attend to the toddler, or carrying bags for them, or offering to get everyone some ice cream. We all need help sometimes. Strike up a friendship, even. It may make all the difference to the family and child.

Second, as the report points out, psychological maltreatment is more about the relationship between the parent and child than particular events. We all have bad days when we snap and say or do things we don't mean--that doesn't necessarily mean anything about our overall relationship with our children. So while intervening nicely is good, it's important to cut people slack, too.

The flip side is that there can be maltreatment going on in families that seem completely fine from the outside. Those children are much harder to help. But we can create opportunities for them to have healthy adult relationships and get support outside of the family, such as through sports and community activities--or just by opening our homes to them. So support and volunteer for youth and family activities in your town--and encourage your kids to invite their friends over. You may create a haven for someone without even knowing it.

If you ever suspect that something is going on with a child, don't try to handle it alone. Get advice from a professional, like your doctor or the school guidance counselor.

It's becoming a trite expression, but that's because it's true: it takes a village to raise a child. That's why minding our own business doesn't really make sense. Our children are our future. They are everyone's business.

Rabies--what you need to know

Posted by Dr. Claire McCarthy July 23, 2012 04:42 PM
When I read about a Spencer child being bitten by a rabid bat that someone picked up out of the water and showed some children, I thought: why would anyone pick up a bat and show it to a kid? Didn't he know that bats and raccoons are the animals most likely to have rabies? 

And then I thought: I bet he didn't. And I bet he's not the only one who doesn't know this and other important facts about this deadly disease. So--here's what you need to know about rabies.

Rabies is caused by a virus that infects the brain. The virus can be found in the saliva of infected animals. Bites are the most common way it's transmitted, but someone could theoretically get it if the saliva got into their mouths, eyes, lungs, or into a scratch.

It's essentially always fatal once the symptoms start. So you need to take it really seriously. The good news is that if treatment (called post-exposure prophylaxis) is given early enough, rabies can be prevented. Because of this, human cases of rabies are very rare.

The most common infected animals are raccoons, skunks, bats, foxes, and coyotes. Cats, dogs, and cattle are the most common domesticated animals to get rabies. It's not very common in squirrels, rats, mice, hamsters and other small rodents.

Bat-proofing your house is a good idea to lower your family's risk. Because the teeth of a bat are small, it's possible that a person could be bit and not realize it. The Massachusetts Department of Public Health has information not only on how to do this, but on how to know if there are bats in your house, how to get them out, and how to capture a bat safely if you find one in your home.

If someone is bit by an animal that might be rabid, the first thing to do is to wash the wound out really well with lots of water and soap. Then call your doctor for advice. 

If the animal that bit can be caught, treatment may not be necessary. Treatment (more on that below) is a bunch of shots. Before starting them, it's nice to be sure they are necessary--either by testing the animal for rabies (which is done on brain tissue after the animal is dead) or quarantining it for 10 days to watch for any signs of rabies. If the testing is negative or the animal is fine after 10 days, no shots are needed! It's okay to wait the 10 days.
  • If your child is bitten by a dog (or other pet) you don't know, talk to the animal's owner (if possible). Find out if the pet has been vaccinated, and get the owner's name and number. I can't tell you how many times I've had to give rabies shots to a patient because we couldn't track down the animal or its owner.
  • Provoked bites--ones that happen because someone was trying to pet or otherwise touch an animal--worry us less than unprovoked ones (attacking for no reason is a sign of rabies)
Treatment is a series of shots. Human Rabies Immune Globulin (HRIG) is given along with the rabies vaccine on the first day of treatment (not necessarily the day of the bite), then the vaccine is given on days 3, 7, and 14. The shots are given in a muscle, usually the arm. They are 100 percent effective if given as recommended.

Don't touch animals, wild or otherwise, that you don't know. It's safer for all sorts of reasons. Teach children that too.

Pet owners can make a big difference in preventing rabies by:
  • Vaccinating their pets against rabies
  • Keeping their pets away from wildlife (as much as possible)
  • Spaying/neutering their pets, so there are fewer stray animals around 
You should always call your local Animal Control if you see any stray pets or animals that are acting strangely or seem sick. Better safe than sorry. And don't try to help the animals yourself.

For more information on rabies, visit the Centers for Disease Control's Rabies site, or the Rabies page on the Massachusetts Department of Public Health website.

Bad lessons in citizenship from the Boy Scouts

Posted by Dr. Claire McCarthy July 22, 2012 10:05 AM
I'm still trying to wrap my mind around the decision of the Boy Scouts of America to ban anyone who is openly gay from membership.

My older son, Zack, was a Cub Scout. I was his den mother. Everyone we met was warm and welcoming and kind. We did fun stuff. It seemed wholesome and worthwhile. We quit not because of any disagreements with them (if the anti-gay policy existed 12 years ago, I was blissfully unaware), but because Zack was busy with swimming and other activities. 

I just don't get it. Okay, they are a private institution, and as the Supreme Court said when they got sued in 2000 by a gay scoutmaster, they are allowed to pick their values. But where I'm stuck is that their website says that they "provide a program for young people that builds character, trains them in the responsibilities of participating citizenship, and develops personal fitness."

Responsibilities of participating citizenship? Isn't tolerance one of the most important responsibilities of citizenship? Even the military has figured this out, albeit a bit belatedly.

The mission statement of the Boy Scouts of America is pretty straightforward--it's to "prepare young people to make ethical and moral choices over their lifetimes by instilling in them the values of the Scout Oath and Law." The oath and law part is all about being obedient, loyal, helpful, friendly, courteous, kind, cheerful, thrifty, brave, clean, and reverent. Okay, tolerant isn't in there, but it would seem to follow from those values. I was still puzzled--until I read the vision statement:

"The Boy Scouts of America will prepare every eligible youth in America to become a responsible, participating citizen and leader who is guided by the Scout Oath and Law."

Eligible. Not every youth, but every eligible youth. And I don't think they mean just boys, because they could have said that. They mean the ones that they want and like. Today they don't like gay people. Who will it be next?

This raises so many red flags. From segregated bathrooms and other forms of racism to George Orwell's "Some animals are more equal than others." Has history (or even just current events) taught us nothing about what happens when we do things like this?

No matter what your values are, or how passionately you believe in them, responsible citizenship should never involve discrimination. The ramifications of your values should never hurt people. That's a lesson we really, really need our children to learn; I wish the Boy Scouts could help us teach it.

By being a den mother, did I lend my support to homophobia in the eyes of those boys? It's a devastating thought. I'm glad that Zack got busy and dropped out, and I'm not going to sign up my 6-year-old son. Which is sad, because in so many ways the Boy Scouts of America is a wonderful organization that has so much to offer our children.

Except the lesson of citizenship our founding fathers made so clear: all men are created equal.


It's terrifying, sometimes, to love your child so much

Posted by Dr. Claire McCarthy July 18, 2012 03:25 PM
The other day, my 21-year-old daughter asked me if she could borrow my car to drive her and her friends to Six Flags next weekend.

She asked as she was driving me (in my husband's car) to pick up said car after an oil change and tune-up. "I'm a good driver, you know that," said Michaela.

I asked how many were going. "Four of us," she said. 

"You know that the risk of an accident goes up the more teens there are in a car," I said, forgetting for a moment that she and her friends aren't teens anymore.

"You've been saying that since I was sixteen," she said. 

"Because it's true," I said. We were quiet.

What was really true, though, was that I was scared.

Whenever I see first-time parents with their newborns in my practice, they all have that same deer-in-the-headlights look. There is simply no way to prepare for how overwhelmed you get when you realize that this wonderful, incredible being is really here, is really yours--and not only are you totally responsible for them, but they could be so easily hurt or taken from you altogether. It's almost too much. 

It is too much. 

But we learn to live with it so that we can make it through the days, so that we can let them go to kindergarten and field trips and sleepovers and first dates and college, so we can function when they first take the car or when they get a high fever or climb a tree. Over time, we even start to feel wise and relaxed and like we've got this whole parenting thing down pat.

Until they ask to take the car to drive a bunch of friends to an amusement park two hours away.

If I don't lend it to her, the scared voice in my head said, maybe she won't go. And she'll be safer if she doesn't go. But that's nonsense, because they can just get another car--one Michaela isn't as comfortable driving as mine, one that isn't straight from a check-up by a mechanic like mine. She is an adult now, not a little girl whose plans I can veto.

But parenthood doesn't have to make sense, and it often doesn't. The truth is, it's plain old terrifying to love someone so much. It's true when they are born, and it's no less true when they are twenty-one--or, I'm told, when they are older. When you sign on for parenthood, that's part of the package forever.

I told her I had to think about it. I'll probably say yes, because I know it's a safe car and I know she is a good driver (I have no idea if her friends are). If she's going to go, it's probably the safest option.

And then I will hug her really tight.


Can we change the culture of high school sports so that more teens get exercise?

Posted by Dr. Claire McCarthy July 16, 2012 02:26 PM

Want to keep your high school student from getting fat? Make sure they play at least two sports during the school year. 

That's the message of a study just released in the journal Pediatrics. Researchers interviewed about 1700 high school students and their parents, asking about how the kids ate and spent their time (and about their height and weight). Of everything, playing on at least two sports teams each year was what made the biggest difference when it came to keeping kids at a healthy weight (walking or biking to school helped too). The authors said that if every student played on two teams,it could cut the prevalence of overweight and obesity by 26 percent. 

I think it's a great idea. After all, we are in the midst of an obesity epidemic, with a third of US kids overweight or obese. Exercise helps, but the problem has been getting kids to exercise. This idea uses something that is available to the vast majority of high school students. Sounds really straightforward--and it's not like there are a whole lot of better ideas out there.

There are, however, a couple of obstacles.

Cost is clearly an obstacle. All over the country schools are having to make cuts in their budgets, and adding a whole lot of new athletes (with the coaching and other expenses that would entail) could be tough. It could also be tough for some families, as many schools charge a fee to be on a team (I paid around $200 for my kids). We'd have to figure out how to pay.

But the bigger obstacle, I think, will be changing the culture of high school sports.

When I was in high school, it never occurred to me to play sports. Back then, I was one of the last picked for kickball, if you know what I mean. I'm reasonably athletic now, but as a teen I was more one of the geeks. None of my friends were on teams, and without friends to do it with you, well, it's kind of a non-starter. Basically, as a teen if you're not good at sports, or if you don't hang out with kids who play sports, chances are you won't play sports. That's what has to change if we want to get kids moving.

We need to follow the example of my son's high school swim team. All it took to make the team was an interest in doing it--and the ability to swim 50 yards or so without drowning. The coach divided the kids up in practice and coached them according to their ability. There were a few kids who, like my son, were experienced swimmers; they helped the newbies out. The team didn't win a whole lot of meets, but the boys had a really great time--and everybody got to be a better swimmer (and got regular vigorous exercise).

We could make high school sports mandatory, I suppose. Some schools do, or do some variation on that theme. It may be the road we end up needing to take, if obesity rates keep rising. But wouldn't it be better if we could make kids actually want to do it? Wouldn't it be better if coaches and school staff and current athletes and others did outreach to the kids who don't usually play sports--and helped them not only do it but enjoy it?

We'd have to be willing to let go of the goal of winning. We'd have to be willing to celebrate teamwork, and individual goals, instead. We'd have to be willing to think of sports as exercise--and as games.

I don't know if we can do these things. But I think we should try. The health of our children is at stake.

How to know if your child is really sick

Posted by Dr. Claire McCarthy July 10, 2012 04:35 PM

When I heard about the deadly strain of hand-foot-and-mouth disease in Cambodia, I thought: wow, this is going to freak a lot of parents out. After all, hand-foot-and-mouth is a really common illness. Hearing that a strain of it is killing children is, well, terrifying.

Hand-foot-and-mouth is generally not a fatal illness--the vast majority of children who get it recover completely with fluids and rest and snuggling. But the reality is that any illness can take a nasty turn. So it's important to know the signs that an illness is taking a turn for the worse. That way you'll know when to worry (and take action) and when not to.

If your child has any of the following, get to medical care immediately (or call 911):

Trouble breathing. How to tell: rapid breathing (or very slow labored breathing), sucking in around the ribs or neck, trouble getting a sentence out, can't stop coughing, skin pale or blue.

Loss of consciousness--like a faint or falling asleep, only you can't shake them awake. Which is similar to but not quite the same as...

Excessive sleepiness, so that it's hard to arouse them, at a time when they aren't usually that way (i.e. if it's three am and they are otherwise fine, not so much a problem).

Seizures (if your child doesn't suffer from seizures)

A dark red or purple rash that doesn't get lighter when you press on it. The spots may be small (petechiae) or larger and more raised (purpura). If your child has fever along with the rash, it can be a sign of a dangerous infection.

Severe pain--or, in an infant or younger child, inconsolability

Hives and swelling of the face, especially if your child is dizzy or has any stomachache or vomiting--it could be a sign of a severe allergic reaction.

While not necessarily reasons to call 911, here are some reasons to get yourself to the doctor's office:

  • A high fever. Notice I didn't give a temperature...because what counts as a high fever is going to depend a bit on the age of your child and whether they have any medical problems. Ask your doctor what temperature you should worry about.
  • A cut that gapes open or won't stop bleeding, because it likely needs stitching.
  • Weakness or dizziness that doesn't go away, especially if your child looks pale
  • An injury that gets very swollen or painful, especially if your child has trouble moving the body part (it could be broken)
  • Vomiting or diarrhea that won't stop, especially if you are having trouble getting plenty of fluids into your child, and especially if they are urinating much less than normal
  • Blood where you don't usually see blood (vomit, poop, urine, etc). Nosebleeds are less of a big deal, unless you can't get the bleeding to stop.
  • A significant change in your child's behavior (acting strangely, can't move or use a body part normally, etc)
I'm probably forgetting something, but I think those are the major points. You should also call if your child's illness, pain or injury isn't getting better--or if your gut tells you that something isn't right with your child. Over the years, I've really come to respect and trust a parent's gut instincts.

While we're talking about scary stuff and what to do, here's a great video about CPR that my wonderful friend Dr. Wendy Sue Swanson shared on her blog. Watch it--it's short and simple and could help you save a life.

I'm a cat person and my family wants a dog--help!

Posted by Dr. Claire McCarthy July 9, 2012 07:28 AM
A study was released this week saying that kids who have a dog around in the first year of life are healthier (the authors think it helps the immune system) and it's adding to my guilt.

My children want a dog bad. And I don't. I am a cat person.

Actually, we did have a dog for a while. Shoki, an Akita, preceded me; he was a great dog, and wonderful with our two oldest children--until he bit Zack in the face when he was a toddler, narrowly missing his eye and leaving a scar (even with multiple stitches by a plastic surgeon). It was an accident--Zack fell on Shoki's sore ear when Shoki was asleep, startling him. But Shoki got sore ears a lot, and we had two small was not an accident I could risk again, so we found a new home for the dog. Since then (that was 1994), I've said that we can't even consider a dog until we have no small children in the house. My eldest child, who has led the campaign for most of her life, says that the reason I keep having kids (we have five) is to avoid getting a dog.

But now the youngest is six. And he's crazy about dogs. 

What makes me feel worst is that my family has given up. They know I don't like dogs, and since for whatever reason I end up having the final say on things, they barely even try anymore. And as much as I don't like dogs, I really want my family to be happy.

So I'm crowdsourcing this one. I'd really like help. Maybe if I tell you why I don't like dogs, you will be able to counter them and convince me on behalf of my family.

Dogs wear me out. They need so much attention, especially as puppies. I'm the early riser of the family (it's when I get most of my writing done), so I figure that I'll have to deal with the dog while everyone is still asleep (and not get my writing done). They jump on you and want you to play with them. Cats, while less abundantly affectionate, demand far less; they mostly amuse and take care of themselves.

I hate dog poop. I really do. Not that I love cat poop, but it's smaller and gets conveniently deposited in a litter box (or, when they go outside, in places I never see). I don't want dog poop in our yard--having to watch your step all the time is no fun. I'm not wild about the idea of picking it up, either--and as that early riser, I figure I'm going to be the one out in the morning doing just that.

Dogs can't be left alone long. Cats can be left all day or even all weekend if you leave them food and water and a litter box; dogs need to be let out and played with. This complicates life; it's something else to think about if for whatever reason we aren't going to be around all day, or when we go away as we do for two weeks every August. I feel like life with five kids is complicated enough.

Okay, guys--bring it on! For my family's sake, can you help me be a dog person?

What "having it all" should really mean

Posted by Dr. Claire McCarthy July 4, 2012 11:58 AM
I have five children, and because of this I will not be as successful or wealthy as I might have been without them. 

I am totally okay with that.

This week I finally read the Atlantic article, "Why Women Still Can't Have It All." My son has been telling me I need to read it, especially since I wrote a post a few months ago about work-life balance. It was a great article; I think Anne-Marie Slaughter did an excellent job of laying out the reasons why there are so few women in top leadership positions--like conflicts between work and school schedules, the difficulties of entering and re-entering the workforce after having children, and how workers who put careers first are rewarded while those who put family first are not. I can relate to all of them.

It's not that I haven't achieved a reasonable degree of success, because I have. I'm a pediatrician at Boston Children's Hospital, an amazing place, and along with seeing patients I work in their Marketing department as a writer and editor. I've also been a professional writer for more than twenty years.  

It has come at a cost, though. I've taken multitasking to places it truly should not go. My alarm is set for 4:20 am--even on some weekend days. I've missed school concerts and field trips and so many other important moments. I've missed meetings I should have gone to, and not been part of projects I should have been part of. I've spent days without seeing my children at all because I've left before they were up and come home after they've gone to sleep. And speaking of sleep, I pretty much never get enough. 

And I'm really lucky. I have a wonderful, supportive husband who is willing to work nights and weekends so that he is home with the kids when I'm not--and a wonderful, supportive mother-in-law who is willing to be there when neither of us can. I have a job that has some flexibility--while I do have to be at the hospital to see patients and go to meetings, writing and editing can be done from home if necessary. Slaughter talked about how having control of one's schedule is crucial, and she couldn't be more right. (Although, for me this sometimes backfires--maybe it's my Catholic guilt, but my ability to work at home often makes it hard for me to relax and not work when I'm home.) So many women don't have the support or flexibility I do.

But at various points in my career, I've said no to something that would have brought me more success or recognition. I've limited my hours. I've limited my travel. I've let opportunities pass. Because ultimately, my first responsibility is to those I brought into this world--and to the person I promised to have and to hold for the rest of my life.

Whenever I hear the phrase "having it all" as it applies to women (interesting that it's not used so much for men), it seems to mean having a highly successful career and being a highly successful parent and partner. This makes no sense to me. In fact, it's absolute nonsense. Having a highly successful career is a full-time endeavor. Being a highly successful parent and partner is too. Until we figure out cloning, nobody can do both at the same time. It makes me angry when people talk about it that way, because it sets women up with unrealistic expectations. One of the most heartening parts of Slaughter's article was when she talked about how the next generation of women seems to understand that mixing career and family inherently involves compromises--and that women make more of them than men do.

I suppose I should be angry about that, but I'm not. I love being a doctor and a writer, but I love being with my kids too. I love being needed by them. They wear me out sometimes, but they are the point. I may be tired and overextended, but I'm doing exactly what I want to do--which should really be the definition of having it all.

My favorite line of the essay was this: "If women are ever to achieve real equality as leaders, then we have to stop accepting male behavior and male choices as the default and ideal." 

Whether it's socialization or our wiring, women have always understood that life involves compromises, that family needs to be first, that happiness and success can be defined in all sorts of ways. If more men could understand and live that (and if our culture could support it), it would open up so many opportunities--not just for women, but for men. Not only would the work be more fairly shared, but many more of us would have a chance to, well, have it all. 

About MD Mama

Claire McCarthy, M.D., is a pediatrician and Medical Communications Editor at Boston Children's Hospital . An assistant professor of pediatrics at Harvard Medical School and a senior editor for Harvard More »

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