Hello, Again, from the Portable Pediatrician!

When we last met, over a decade ago, we probably talked about children: yours, and occasionally mine, from newborns to high school Seniors. You were parents or loving caretakers of those babies, and I was your pediatrician, whether in person at El Camino Pediatrics in Encinitas, California, or through the written word, in my books. ...continue reading

Foreign (Object) Affairs

What I really want to do is remind everybody how dangerous those tiny rare-earth magnets are, how irresistible to see what they taste or smell like, how potentially lethal when swallowed. Not just to small children; a teenager reports having swallowed some when she put them in her mouth rather than on the bathroom floor and then “somebody said something funny and I laughed.” Surgery followed.

But you already know that, so instead I will share with you a bouquet of Foreign Objects In the Orifices of Small Children.

Tammy was Two and a Half when she invaded her mother’s jewelry box. It was Tammy who taught me the lesson: If you remove a pearl in the right ear, Look again!  There’s another pearl behind it. And don’t forget to check the other ear. And the nostrils. And as you pull them out, don’t just put them on the drape: Give them to Tammy’s mother, so Tammy doesn’t just reach out and—oh dear.

One of the less common things I found in an ear was a little slip of paper the size and shape of a fortune in a fortune cookie.  As I extracted it, Howie’s mother and I waited with baited breath to see what Howie’s fortune would be. It said, “Inspected by #8732.” “Ah. I always wondered,” said Howie’s mother.

And then there was Filiberto, who had just turned Two. It was a rare rainy day in San Diego, and the office was jammed with children, their siblings, their parents, an entire daycare with Fifth Disease—the noise and excitement were at their higher levels.

Without appointment, in comes Filiberto, clutching his nose, looking scared, mad, and guilty. I was pretty good friends with Filiberto and his Mom, we’d been through a lot together.  “Ice plant,” she said, shaking her head. “Way up there.” So I looked, with unexpected cooperation from Filiberto. It was. Way up there. The tough stem of a groundcover succulent plant.

Now when a child has an object that far up hid nose, one worries that he will sniff a big sniff, suck it back in his throat right into the airway, where if it doesn’t block his breathing completely but instead gets inhaled into his lung,  he’ll need anesthesia and an expert with a scope to get it out. If you’re lucky. So you don’t want to fool around poking up there with the Nose Curette. Especially if the office has run out of nose-numbing drops.

Of course, I could send him to the emergency room but it’s the height of flu season. I could call the pediatric Ear Nose Throat doctor, but I happen to know that at the moment she is operating on another of our patients, who managed to  perform a self-tonsillectomy by running and tripping with a spoon of Dimetapp in her mouth.

Time is of the essence, not just because of the potential sniffing of the ice plant, but because I am running forty-five minutes late and people are getting restive. I am also monitoring my medical student, a lovely guy whose first and second languages are not English but who smiles a lot and earnestly writes down in a foreign alphabet every word I say and every move I make. And then there is my terrific Medical Assistant, Keri, whose due date is a mere week away but the baby has dropped and she is two centimeters dilated, and we are both a little nervous.

So I look at Fil’s mom and said, “We’re going to try something a little different.” And explain. She looks dubious but trusting.

Keri persuades Fil to lie down on the exam table. His mother bends over him and flirts a little and asks him to open his mouth big and wide. He does. She takes a giant breath in, and then puts her open mouth on his, and while I press my finger against the unoccupied nostril she blows. Hard.  There is nowhere for that breath to go except the nostril with the ice plant in it.

I look inside. “It moved!  It’s coming down!”

We do it again, this time with Keri as our cheering section. “Push! Push!” she yells.

More success, but it is still unreachable.

Third time: A huge effort! And out pops the Ice Plant from his left nostril, ust as Mom lets go of Fil and just as he sits up and as he does so takes a big breath and—goes silent, puts his hand to his neck, and turns blue.

He’s aspirated the same blankety-blank ice plant!

I grab him off the table and give him a Toddler Heimlich. The ice plant flies  out of his mouth and he starts to yell. Keri collapses palely on the floor with her head between her knees, not easy in her condition.  Mother of Filiberto looks at me suspiciously. “Was all that supposed to happen?” she says.

And the medical student is still taking notes.

Sometimes I wonder whether he has used this technique in his own practice, probably thousands of miles away.

Show and Tell

Last time, I summarized the findings of the BMI (Body Mass Index) charts that the Centers for Disease Control (CDC) distributed in 2000. The BMI number for children below the age of puberty is a pretty accurate number for the percentage of body weight that is fat. So watching the curves go up and down on the chart tells a story.

But what’s a story without illustrations!

So here’s that summary again, illustrated:

Baby Fat

From Birth to 8 Months of age, babies gain weight as fat. This complacent normal infant illustrates how adorableness and adiposity (chubbiness) go together in the very young.

Note the extra chin, chubby cheeks, and non-elbow creases in both upper arms and forearms. (And there are two more in each thigh. I looked.) At 8 months, babies start slimming down, slowly, month after month after month. That is, the BMI number rises more slowly. BABIES DO NOT LOSE WEIGHT, HOWEVER. They grow in length while slowing down weight gain

One Year Old in Dress

By a year of age, they’ve still got the slightly chubby cheeks, and belly, but no creases in the arms or thighs:

Baby in Bath

At Two Years of age, the belly is diminishing, and the chin is well defined,

At Three, no more belly.

Throughout Four and Five, the arms and legs grow longer and skinnier.

Boy in tree

By Age Six Years, Cherub resembles the stick figure drawing beloved of Kindergarten teachers and parents.

stick figures

Starting at around Seven, the BMI starts going up, steadily and slowly, right through Puberty. That is, weight is gained as fat, but slowly. The growth spurts at puberty for both boys and girls have to do with height and bone and muscle growth. Not even the CDC is sure how much fat, as opposed to “lean mass,” plays a role in prepuberty weight gain.

Nonetheless, the CDC chooses to emphasize the weight gain that occurs after the lean point rather the lean point itself. They call it “adiposity rebound,” or Fat Rebound, and worry about children whose Fat Rebound occurs earlier than Six Years. That’s associated with a risk of obesity in later life and adulthood.

But they hedge their bets about that weight gain by putting “adiposity” in quotation marks. As one might do with “Fat” Rebound.

The CDC is sure that children who follow a path that is not parallel to this “average” route are at high risk for overweight and obesity.

At age Eight Years, most children will have established the category of Adiposity (average, leaner than average, heavier than average, much heavier than average; and thus the Percentile Rank) that will be theirs for all the rest of their growing years. That is, there’s practically no chance of “slimming down” during puberty.