Okay, so my job involves meeting people in small windowless rooms. The air in these rooms doesn’t circulate well, meaning an odor penetrating the space hangs around until it’s chased away by the passing of time. If the aroma is a particularly foul one or if it seems to have the staying power of a dead skunk, we hurry its exit with a few short blasts of a better-smelling aerosol.Some of the smells are predictable and unavoidable. Take, for example, baby poop. It’s a pediatrician’s office. Babies poop. Diapers go in the trash can, and the smell drifts out. You simply have to expect it and empty trash cans often.Sometimes the smell is my fault. I have a nasty habit of eliciting strong gag reflexes in the course of obtaining throat cultures. Fortunately, my nursing staff comes to the rescue, cleaning up the splattered mess. I’m afraid I wouldn’t be so lucky at home.Then there’s a smell parents can and should avoid, but don’t: cigarette smoke. Now here’s where it gets tricky. I’m seeing a kid who’s wheezing, and the exam room smells like a bowling alley. Do I mention something or not?Body odor is another example of a preventable smell, and again the question stands tall: What do I say–if anything?And here’s one I still don’t get–litter box families. Seriously, some folks smell like cat pee. No joke. In fact, there have been times when I wander down the hall, catch a whiff, and correctly predict the child I’m about to see.Recently, I read meth labs are associated with a “cat urine” smell. This complicates things a bit. Should a doctor, or teacher for that matter (since I’m sure these kids smell the same at school), confront litter box families in some way? Should we call children’s services or law enforcement because of a particular odor? Of course, there’s no question if signs of abuse or neglect are present. But what if it’s just the smell? Then what?A pediatrician’s week is full of these and a hundred other little non-medical questions. You don’t learn the answers in medical school or residency or even in the course of your practice. Indeed, the answers may change from one day to the next, often dependent on little variables along for the ride.The art of medicine–that’s where you file these questions. It’s a big part of being a doctor. A part the nose comes to know quite well.

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Following the controversial subject matter of my last podcast, I feel the need to lighten things up.Enter Dingle, our killing cat.Remember Toonces the Driving Cat from Saturday Night Live? Well, let me tell you–he’s looking pretty darn good right now, even with the poor driving record and high insurance premiums.It all started six years ago, when we invited Dingle (don’t ask how he got his name) to live outside. You see, he thought the world was his litter box. The vet gave him a clean bill of health; so we, in turn, gave him a bigger world to do his thing. Honestly, I didn’t think he would survive a year. We live in a fairly rural area–not so backwoods we’re still on dial-up, but somewhat isolated all the same. The back of our property leads to a mile-long cornfield, and the road next to us is fairly busy with little red trucks, thanks to the Staples Regional Distribution Center a few miles away. Suffice it to say (animal rights folks, please turn your heads now), we thought he’d end up lost or flat on the road.We were wrong.As it turns out, Dingle has special skills that would put Toonces to shame. Despite his lack of front claws, he holds his own against stray cats and raccoons and opossum. He avoids the busy road at all costs, but is happy to roam the big field in search of dietary supplements. And typical of his breed, Dingle likes to share his catch–as if he’s providing for us. So nearly everyday, he leaves the left-overs on the back porch.Well, mice meals are fattening, and over the years Dingle has grown to the size of a small dog. This presents a problem: the field mouse is no longer filling. Plus, I don’t think it’s enough of a challenge.So he graduated to chipmunks.Now keep in mind, my kids are Disney nuts. In their eyes, Chip and Dale are right up there in importance with the President of the United States. So the transition to chipmunks, especially when they began showing up in pairs, did not sit well with them.And so, over the past month, our porch has come to resemble a chipmunk battle field–a clear indication chipmunk tastes better than mouse or a sign the mice have packed up and moved on (it took them long enough).But it doesn’t stop there.Two days ago, Dingle brought us a squirrel! I’m not kidding. A squirrel.And yesterday? It was a large bird–like he’s running down the list of wildlife living in our neck of the woods.I’m not sure what we’ll find out there today, but just to be safe, we’re keeping the kids inside!

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Clear the trophy shelf for another industry first from the Walt Disney Company. That’s right–move over Steamboat Willie, watch out Snow White, make way Disneyland–the mouse has a new trick up his sleeve, one he hopes will catch-on with parents and cash-in at the register. And I think his plan has more than a fighting chance.We’re not talking about a one year promotion like the “Million Dreams” campaign. This initiative promises to be a corporate fixture for years to come. It’s a move that arrives two years after the Kaiser Family Foundation released a report reviewing more than 40 studies on media’s role in America’s childhood obesity epidemic.The report concluded that the kids who spend the most time with media are the ones most likely to be overweight. As my daughter would say, Duh! But there’s more. The report states, contrary to popular assumption, media use does not appear to displace physical activity. In other words, kids who watch lots of TV are just as active as those who watch little.So what gives? Well, the report suggests children’s exposure to billions of dollars worth of food advertisements may be the culprit. The typical child views more than 40,000 ads a year on TV, and a majority of these commercials promote fast food, soda, sweetened cereal, and candy. What’s more, ad campaigns plugging these products often enlist characters from the shows kids watch. Thus, we have Sponge-Bob Cheez-Its and Scooby-Doo cereal and Teletubby Happy Meals.The research also indicates exposure to food advertising affects the choices kids make when eating out and shopping at the grocery store with mom and dad.Enter the Walt Disney Company. This week, CEO Robert Iger outlined new guidelines for food licensed to carry the Disney name and characters. The new policy limits added sugar to 10% of total calories for main and side dishes and 25% for snacks. Likewise, total fat will not exceed 30% of calories for main and side dishes and 35% for snacks. The company also plans to to completely eliminate trans fats from all licensed and promotional food products.The food Disney serves at its theme parks will also conform to these guidelines.Iger kicked off the nutritional campaign saying, “The Disney brand and characters are in a unique position to market food that kids will want and parents will feel good about giving them.”But don’t expect these changes to happen overnight. Disney has to wait until current licensing contracts expire before making many of the changes. In fact, the reason this initiative comes two years after the Kaiser Family Foundation’s report is in large part due to Disney’s decade-long exclusive partnership with the McDonald’s Corporation. With that agreement now under the rug, Disney projects all theme park food will reflect the new rules by the end of 2007 and all licensed and promotional food items will fall into line by the end of 2008.So how do these nutritional guidelines stack up to those recommended by pediatricians?Actually, they match up pretty well. This past February, the journal PEDIATRICS published Dietary Recommendations for Children and Adolescents: A Guide for Practitioners. In the article, nutrition experts recommend children get <30% of their total daily calories from fat. They also recommend <7% of total calories come from saturated fat. While Disney plans to eliminate artery-clogging trans fat, they make no specific mention of saturated fat, which they should have done to keep the guidelines in step with current nutritional thinking.Still, it’s a great start–one that will prove financially successful and provide encouragement to other companies who market to children through media.Understandably, there have been rumblings on the DISboards concerning changes in the kid’s menus at theme parks. The healthy choices aren’t popular with little tourists. I see their point. While I advocate the American Academy of Pediatrics’ nutritional guidelines, I also understand a well-balanced diet of moderation allows wiggle room for the occassional splurge. Let’s face it, a Disney vacation is an occassional splurge. Does it really matter kids aren’t following guidelines the few days they’re on vacation? And what about the cruise line? Will their meals conform as well? If so, I will officially join the DISboard outcry. No more creme brulee? Say it isn’t so!With regard to fast-food and grocery-item licensing, I’m all for the new plan. Creating a line of products kids identify and parents trust is a smart marketing move. I give Disney kudos for their effort. With new leadership at the helm, I hope bold innovations from the Walt Disney Company continue into the months and years to come.

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Since we have a series about the flu, I want to share a really frustrating situation regarding flu shots. Despite assurances that this year’s supply would be plenty, our office is having trouble getting them. We have had zero shipments from the state, meaning kids on Medicaid and the state HMO programs haven’t yet been vaccinated–and that includes young kids with chronic diseases such as asthma. They’re the ones who REALLY need flu vaccine.The private insurance patients aren’t fairing much better. We had infant flu shots last week, but ran out quickly since the recommendation this year calls for all kids ages 6 months to 5 years to get the shot.Now we only have one type of injectable flu vaccine in our office, but here is where the real frustration lies. This flu vaccine is made by a British company who tells us their product is only licensed for children 4 and older.The infant flu shots (the ones we ran out of) are licensed for ages 2 and under only.So what about the 3 year olds?We have nothing for them, even though the CDC and AAP recommend they get vaccinated. We do have an order pending for flu vaccine from an American company that is licensed for ages 3 and up, but haven’t seen hide nor hair of it.As best we can tell, the British flu vaccine is identical to the American vaccine. But since the Brits only tested it in the 4 and over crowd, they don’t want to say we can use it for 3 year-olds.It gets worse. As doctors, we use drugs “off label” all the time, without fear of malpractice as long as that off-label use is the “standard of care.” So, with informed consent, we could use the British vaccine in 3 year-olds, as long as parents know the entire story. I feel comfortable doing this, because there appears to be no difference between the British flu vaccine and the American one.BUT, if we do that, and a kid has a severe allergic reaction or some other adverse event, you can bet the lawyers will say, “but that shot was only for 4 and older.” And they’ll say this despite our getting informed consent from the parent, claiming we shouldn’t have asked.On the other hand, if we don’t offer the British vaccine, and a kid gets pneumonia and dies, then we are faulted for not offering what we have. Now the lawyers argue giving the flu vaccine to a 3 year-old is the standard of care and we should have let the parents make the choice.The crazy thing is that the same lawyer will argue either way, depending on if the vaccine or the pneumonia injured the kid. I guess it’s just the nature of the lawyer’s job.Just as it’s my job to figure out what to do for 3 year-olds with regard to flu vaccine this year.What would you do?

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This year the Centers for Disease Control and the American Academy of Pediatrics are recommending routine flu vaccines for all children ages 6 months to 5 years. The rationale for this recommendation comes from the fact that young children are at the greatest risk of developing significant complications of the flu, including pneumonia and dehydration, which may require hospitalization.I make a habit of informing parents of this recommendation when I see kids in this age range for well-child checks. Of course, parents ultimately decide if they want us to give their child a flu vaccine. Most moms trust these organizations and agree to let us vaccinate the child in question. Sometimes parents ask me if I think flu vaccines are a good idea. I do, and I tell them so.Then there are the few parents who say they would rather not. Now, don’t get me wrong–I’m all for the right of parents to make sound decisions for their children, but I’m also curious how parents arrive at a decision not to vaccinate. So I ask moms and dads–why don’t you want us to give your child a flu shot?It’s not an accusation. It’s not a judgment. I’m simply curious how they arrived at the decision to disagree with the scientists who study influenza.Unfortunately, I rarely get a thoughtful answer to my question.This morning I had two parents refuse the flu vaccine. One wanted to follow the recommendation of two women at the health-food store who told her flu vaccine is “poison,” and the other wanted to take the advice of the guys down at the airbase who claim the vaccine gave them a bad case of “sinus congestion.”I wonder what these parents would think of the two ladies at the health-food store or the guys down at the airbase while sitting next to their child’s ventilator in the ICU of a children’s hospital. I know, it sounds like I’m employing a scare tactic with that statement. Let me assure you–I realize most kids who get the flu recover nicely. But some don’t. And the trouble is you can’t tell which young kids will be in that boat until it’s too late.I simply let these parents know they’re going against the advice of the pediatric community and that I will note their refusal in the chart. I have to. If a child dies from flu complications, these very parents might get a lawyer and claim I didn’t tell them what could happen if their child gets the flu. I also try to provide these parents with as many facts about immunizations as I can without trying to make them feel guilty or browbeaten.In the end, one of these parents decided to go ahead with the flu vaccine and the other wanted to talk it over with Dad and get back to us.Honestly, I respect a parent’s decision, even if it’s not the decision I would make. But please, if you are trying to decide, consider the sources you are comparing. I don’t think the ladies at the health food store or the guys down at the airbase have done much investigation into the results of statistically significant research studies.On the other hand, the recommendations of the American Academy of Pediatrics and Centers for Disease Control are based on factual information, not fears and supposition. I’d go with them.

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