Heartfelt Thanks

staffpicA heartfelt thanks to the physicians and staff I have had the pleasure working with all these years, and of course, to my patients for your trust and confidence. I can hardly believe it has been twenty years. This will be my final week in Tarzana. Thank you! I will miss you and hope to see some of you in my new office!

Letter to Patients copy.jpg

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Eighteen Years

18 yearsA lot can happen in eighteen years. This year is extra special for me. When I began practicing pediatrics, many of my patients were just entering this world, newborns in the shaky hands of exuberant, anxious parents. Today they come to see me, some driving themselves over, getting ready to graduate high school.

Some tower over me. One brings me flowers because she knows it’s her last visit with me. Another beams as he tells me about his lacrosse scholarship. One laughs because she can hear a baby crying in the next room and she suddenly feels so grown up. I see prom pictures and hear about college acceptances.

I remember their fevers, colds, rashes, pneumonias, and ear infections. Their parents wondered when they would sleep through the night, deliberated over where to send them to daycare or preschool or kindergarten or camp. I can’t forget the day they became big brothers or sisters for the first time. I saw them as they learned how to read and tie their shoes. I took care of their headaches, stomach aches, and sore throats. Later, we talked about periods and acne and boyfriends and girlfriends.

Now here they are, eighteen years later, getting ready to start the next eighteen years. I stand with their parents, wondering how it ever happened and how it all happened so quickly. And as I end the day, I head to the hospital to welcome a new patient into my practice and into the world.

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Blessings In Disguise

Happy New Year 2013

The New Year is a great time to count our blessings, like good health, family, and friends, but the ones in disguise can often be a little harder to count because they hide in places where we don’t usually look. These blessings in disguise cause difficulties at first, but then turn out to be the best things that could have happened.

As a pediatrician, I have the unique privilege of supporting families through the many challenges of raising their first child. During the first year, I see them triumph over sleepless nights, bouts of unremitting colic, and a wide range of nasty viruses.  By their baby’s first birthday, these parents have earned a degree in sleep training, baby soothing, and nasal suctioning.  By their little one’s second birthday, they have mastered the technique of “time out” and become proficient at art projects made from feathers, glue, glitter, and paint.

Often, just as they seem to be mastering the art of parenting, the next child comes along. Amidst the excitement and anticipation of the newest family member’s arrival often lie fear and anxiety. “How can we possibly do a good job raising two kids?” they wonder. “It’s hard enough to raise one!”  Parents worry about not having enough time and attention to devote to their first child when they’re busy feeding, changing, holding, rocking, and soothing the new baby.

And so the new baby arrives. While his parents are lamenting not being able to help their first child get dressed, he figures out how to do it himself. While they’re too overwhelmed to read him another book, he picks one up and starts to learn how to read on his own. And just as they’re starting to feel guilty for not starting the art project they had planned, their first child has created an incredible masterpiece all alone.  Incredibly, this perceived lack of time and attention has fostered the assets of independent learning and creativity.

So count your blessings this year and please don’t overlook the ones that can be harder to find, the blessings in disguise. Happy New Year!

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Staying Focused

Attention deficit hyperactivity disorder (ADHD) is the center of attention once again in a recent New York Times Article about a pediatrician in Georgia who prescribes ADHD medication to patients who do not have the disease (Attention Disorder or Not, Pills to Help in School). Dr. Michael Anderson’s goal is to boost the academic performance of struggling students by prescribing medication because it’s easier and cheaper to modify the child than to change society.

As a pediatrician, I encounter concerns about school performance regularly and find his approach particularly disturbing. ADHD is a disorder involving inattention, impulsivity, or both, often treated with a combination of behavioral therapies and medication. A child can have difficultly paying attention for a variety of reasons, some fairly simple, others far more complex.

Often, poor nutrition is to blame. A large percentage of my patients admit that they skip breakfast in the morning. Either they don’t have time to eat, or they’re just not hungry, they tell me. On the other end of the day, the issue is often sleep. Many children stay up too late, missing out on the sleep they need to feel energized the next day. Of course, a hungry, sleepy child will have trouble paying attention in class.

Far more complex are anxiety and unrealistic parental expectations. Anxiety can stem from a stressful social situation involving friends or family. Sometimes well-intentioned parents can overwhelm a child with too many activities or unrealistic expectations. All children have strengths and weaknesses and not every child will excel in every academic area all of the time.

While ADHD is out there and treatable, there are plenty of children who need our attention in many different ways.

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Say “Ah!” — Strep and Sore Throats

These days, many childhood illnesses have become extremely rare. But some, like strep throat, continue to be a rite of passage for school age children.  An update by the infectious Diseases Society of America published in this September’s Clinical Infectious Diseases reviews what we know about strep and sore throats. As kids head back to school to meet their teachers and make new friends, this is a good time to review some of the key facts about a germ they might encounter along the way.

Strep throat is the most common bacterial infection of the throat and is caused by Group A Streptococcus bacteria. It’s extremely rare in children under the age of three and most common in children ages five through fifteen, although anyone can get it. It’s spread through contact with nasal secretions or saliva and usually presents with throat pain, fever, difficulty swallowing, and swollen lymph nodes in the neck. In children, headache, nausea, vomiting, and abdominal pain are also fairly common. On the other hand, typical cold symptoms, like runny nose or cough, and the absence of fever, make strep throat a lot less likely.

Although strep throat is not usually dangerous, it can sometimes lead to other infections, like ear infections or sinusitis, or more serious complications, like rheumatic fever, which can affect the heart, joints, and nervous system, and glomerulonephritis, an inflammatory condition affecting the kidneys.

A child with possible strep throat should be examined, and if strep is suspected, a rapid test can be done in the office to diagnose the infection. While a positive test is fairly reliable, a negative test is often backed up with a throat culture, which can take a few days.  Strep is treatable with antibiotics, such as penicillin or amoxicillin, which can reduce the duration and severity of illness. Generally, children are no longer contagious after taking antibiotics for twenty-four hours, presuming that fever is no longer present and they are feeling better.

It’s important to realize that strep doesn’t always cause problems in our children’s throats. It can often be found “hanging out,” doing no harm at all, while a virus may be the source of their illness. In fact, the authors point out that only a small percentage of patients with an inflamed throat (20-30% of children and a smaller percentage of adults) have strep.  These viral infections resolve by themselves, without antibiotics. A proper diagnosis can help prevent unnecessary antibiotics, avoiding resistance and the risk of harmful side effects.

So for most sore throats, rest, fluids and pain relief work well — I often do prescribe ice cream and popsicles. But the tricky part is figuring out which sore throats need a little bit more.

For more on strep throat:

Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America

U.S. National Library of Medicine


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Here Comes The Sun

With the kids starting camp this week, I headed out to the store to replenish our supply of sunscreen. The choices are truly overwhelming — stick, lotion, continuous spray, not to mention the differences in SPF, price, and a host of other factors. So I was glad to hear NPR’s coverage on the Federal Drug Administration’s new sunscreen labeling requirements.

These new requirements should make it a lot easier for parents to select an appropriate sunscreen for their families. Basically, the term “broad spectrum” could only apply to sunscreens that protect against UVA and UVB rays. Both can contribute to skin cancer, but UVB rays are responsible for sunburn, so it’s important to apply a product that protects against both. Water resistance claims on the product’s label will have to specify the amount of time a user can expect to get its level of protection while swimming or sweating. Finally, the labels on products that are not broad spectrum or have an SPF value less than 15 will be required to warn that they protect only against sunburn, not skin cancer or early skin aging.

Although in sunny L.A., I’m constantly reminding families to protect themselves in the sun, summer is an especially good time to review the basics. The goal is to protect against sunburn now and skin cancer later in life. The American Academy of Pediatrics (AAP) provides some great guidelines worth reviewing, including limiting sun exposure from 10 a.m. to 4 p.m., when the sun’s rays are strongest. Cover up with fabric that lets a minimal amount of sun through, and wear hats and sunglasses. Use sunscreen whenever possible. For babies under 6 months, the AAP recommends using sunscreen on the face and back of hands only, when protective clothing and shade are not available.

When it comes to sunscreen, protection against UVA and UVB rays is key and the SPF should be at least 15. Apply a liberal amount of sunscreen at least 15-30 minutes prior to sun exposure and remember to reapply sunscreen after 2 hours, and especially after swimming and sweating. Unfortunately, the new FDA labeling requirements won’t go into effect until next December, so take the time to read those labels carefully, and save a nice spot for me in the shade.

For more information:

NPR’s story on the FDA’s new sunscreen labeling requirements

Guide to Sun Safety from The American Academy of Pediatrics

More from The Food and Drug Administration (FDA)

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If I Were Mayor

Mayor Bloomberg’s plan to attack obesity in New York City includes a ban on the sale of many large sugary drinks in restaurants, theaters, and street carts. According to the New York Times, his proposal would limit the sale of any cup or bottle of sweetened drink larger than 16 ounces, with the exception of fruit juices, dairy based drinks, diet sodas, and alcoholic beverages.

If I were Mayor, my plan would be different.  Instead of instituting a ban on a single type of food or drink, I would convey the messages that I share with my patients and their families every day about healthy eating and encourage them to make the right decisions for their own families.

First, moderation is key. Encourage your children to enjoy good food, but in the proper amounts and in the right proportions. There’s nothing wrong with an occasional treat, but too many too often is problematic.

Second, put a positive spin on healthy food. Kids will love vegetables if you celebrate their colors, flavors, and textures from an early age instead of portraying them as foods that they “have to eat.” What kid doesn’t like parading through a farmers market sampling the best produce of the season?

Finally, be a good role model. Your kids will imitate your behavior whether you like it or not. So if you want them to learn how to eat properly, make sure you do the same. According to the New York Daily News, an article in the May edition of the American Journal of Clinical Nutrition  found that parents who persuaded rather than ordered their kids to eat their vegetables had kids with healthier eating habits. I occasionally see children for their annual checkups who admit to me that they don’t eat any vegetables at all.  When I ask their parents about their own nutrition, they will often tell me that they don’t eat many vegetables either.

So strive to provide balanced nutrition for yourself and your family. Enjoy your food and encourage your children to do the same. Take good care of yourself because by observing you, your children are learning to take good care of themselves.

And go ahead and enjoy that 32-ounce soda at the theater this weekend, but share it with a friend — or two, or three, or four.

For more information:

 The New York Times: New York Plans to Ban Sale of Big Sizes of Sugary Drinks

 The New York Daily News: Eat your veggies if you want your kids to eat theirs: study 

 Solid advice on healthy eating: Choosemyplate.gov



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I Love to Travel — Germs do, too!


With summer around the corner, I’m reminded about how much I love to travel. Even if I don’t log too many miles myself, it’s always fun to hear about trips my patients are taking.  A report in this week’s Morbidity and Mortality Weekly Report (MMWR) reminds us that germs love to travel as much as we do.

The Center for Disease Control (CDC) reports that a measles outbreak last summer was traced to a fifteen-year-old refugee from Burma who arrived in Los Angeles on a flight from Malaysia. He developed a fever and rash a couple of days before the flight and was seen in an emergency room the morning after his arrival. Measles was suspected and later confirmed. Two young children, both seated nine rows from him on the plane, as well as a customs officer who interacted with him at the airport, were also diagnosed with measles.

For those of you not familiar with measles, it’s caused by a highly contagious virus spread by droplets from the nose, mouth, or throat of an infected person. Chances are that if you’re exposed to measles and not immune through vaccination or prior infection, you’ll become infected. Symptoms develop within 8-12 days after exposure and commonly include fever, rash, cough, and characteristic bluish-gray spots inside of the mouth. Common complications include ear infections, bronchitis, and pneumonia. Rare complications include encephalitis, or irritation and swelling of the brain, often leading to brain damage. This only occurs in about 1 of every 1000 patients infected but is fatal about 10% of the time.

Fortunately, the measles vaccine is extremely effective, resulting in immunity over 95% of the time. In the U.S., two doses of the MMR (measles, mumps, and rubella) vaccine are recommended routinely for children. The first dose is recommended at age 12-15 months with a booster at age 4-6 years. It’s easy to forget how serious a disease like measles can be when you rarely see it. Worldwide, measles remains a leading cause of vaccine-preventable childhood mortality according to the World Health Organization (WHO), resulting in thousands of deaths annually. However, high vaccination rates in the U.S. have made measles relatively rare.

Parents sometimes tell me that since they aren’t planning to travel with their children yet and measles is so rare here, their children don’t need the vaccine. I think this week’s report in the MMWR is a nice reminder that we’re not the only ones who like to travel. Germs do, too.

For more information:

Morbidity and Mortality Weekly Report (MMWR)

U.S. National Library of Medicine


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I’m so excited to welcome you to my blog, Pediatric Perspective. I hope that you’ll find my site informative, interesting, and inspiring. An important part of my job as a physician who takes care of children is to remain up to date on current investigative studies, treatments, and trends related to the care of children. My goal is to use my training and clinical experience to help you wade through some of the often complex and bewildering topics that present themselves daily. I welcome your feedback and participation. Thanks for visiting!

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