The Power of Touch- Progress on a Great Sense

The Power of Touch- 

Progress on a Great Sense

In May of 2106, The New Yorker  published a deeply fascinating review of recent advances in understanding a sense that all people have, but few of us stop to consider:  touch.

http://www.newyorker.com/magazine/2016/05/16/what-the-science-of-touch-says-about-us

The article is loaded with many fun facts, but I will highlight three of them:

1.  The organization of touch 

2.  Progress in reproducing touch

3.  The essential nature of touch

The Organization of Touch

All senses in the body, including taste, vision, and hearing, are organized by the detection of a signal being translated into a nerve impulse that the brain then converts into a perception.

A word on each of these steps should be helpful, and hopefully, interesting.  Think about vision. Vision happens when light in the world is converted by our eye into an electrical nerve impulse that our brain transforms into a visual picture of the world.  This requires a special sensor that converts the light into a nerve impulse, and that would be the light-sensing cells of the retina.  When light hits these cells, they create an electrical charge that shoots down a series of nerves to the brain.  Once the pattern of electrical impulses from the eye hit the brain, the brain turns those patterns into all the extraordinary things we see.

Two more thoughts on this process:  the sensor for each sense is very specific for that sense.  The retina can only turn light into nerve impulses, it cannot do that with sound.  That is why the eye can only see, it cannot hear.   And, all nerve impulses are the same, a nerve can only be quiet or shooting an electrical signal, it is either on or off.  The nerve impulses from the tongue are the same as from the eye.   But there are literally billions of these nerves and it's their pattern that carries the information from the sensor and allows the brain to perceive.  Think of the lights on a movie marquee, each light bulb can only be on or off, and all the light bulbs are often the same.  But the pattern of their going on and off gives the sense that the lights are moving around the marquee.  Pattern causes information.

For touch, the sensor is a special nerve ending that makes a nerve fire if it is squeezed.   It turns out that if the sensor is squeezed, a nerve signal is created, which goes to the brain and creates our perception of touch.   Touch also includes the ability to sense a vibration, or temperature, but this discussion will focus on the simple notion of touch itself.    The variations of pressure allow us to sense all that we do about the world via touch.   Our fingers, and much of our skin, are able to distinguish very minute differences in texture, for example, a soft satin, or a satin that is a tiny bit stiffer.  Or more easily, the feel of wood v. glass, or a pencil point v. a pen point on paper v. cardboard.

Three observations now can be shared about the way touch is organized in our nerves and minds:

1.  The brain detects incoming signals about touch in a frequency of 1 impulse per second.  

The information that the brain manages comes in the form of waves of electricity, in particular differences in waves.   So for touch, the essential wave is a pulse of electricity that beats once a second.  Variations in this pulse actually carry the information of touch to the brain.  Interestingly this rate of electrical pulsing is essentially the same as the rate of a heartbeat.

2.  There are several separate systems of touch, itch has its very own set of nerves.  It turns out that some nerves that deliver the touch signals to the brain cover many areas of function, including pain and sensual pleasure.   But itch has a separate system of nerves exclusively devoted to delivering that message to the brain where the sense of feeling itchy actually comes alive.

3.  The general system of touch nerves can deliver different experiences of touch.  As noted above, pain and sensual pleasure touches are experienced through the same set of nerves.  But the setting of the activation of the touch signals varies.

Progress in Reproducing Touch

As the essay notes, there has been astounding progress in reproducing touch.  Perhaps the most amazing steps forward have involved the development of a pen like device that can dial up almost any touch texture.

You can set the device to create the sensation of wood, and your hand holding the "touch pen" will soon experience the sensation of touching the type of wood you selected.  Or plastic, or silk, or paper, whatever the texture, the pen will recreate the sensation of touching it.  It is designed to help people with injuries re-experience various touch sensations, but it remains extraordinary that scientists can recreate the wide variations of our experience of touch.

The Essential Nature of Touch
Perhaps one of the most interesting insights from this essay is how essential touch is.

Many people will over time suffer loss of vision or hearing, or even be born without these senses, but there are no reports of a person losing their sense of touch.    It is the least of the senses discussed, but may turn out to be fundamental to being alive and human.

There are even specialists in neuroscience who think touch is the best way to understand our consciousness, that is, our awareness of the world depends greatly on what we touch.

BOTTOM LINES

The article in The New Yorker from May, 2016 offers a rare inside look at the sense of touch.

http://www.newyorker.com/magazine/2016/05/16/what-the-science-of-touch-says-about-us

Reading it will give you amazing insights into how senses are delivered and experienced by our brains, new insights on how touch functions are organized into systems, and the great and essential role touch plays in our lives.

To your health,
Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Advanced Pediatrics, Who's the Boss Parenting Academy Note that Sleep Training Comes of Age

Advanced Pediatrics, Who's the Boss Parenting Academy Note:

Sleep Training Comes of Age

The #1 reason parents hire parenting consultants in NYC and LA is to find an approach that lets everyone in the family get a full night's sleep.

This is why Susan Glaser and Dr. Lavin teamed up in 1994, about 22 years ago (!), to develop approaches to teaching one's infant and child to sleep through the night based on their already extensive experience in helping so many families succeed in this quest.

That collaboration led to the publication of their philosophy of parenting and specific how-to's to help families achieve all night sleep in:  Who's the Boss: Moving from Conflict to Collaboration (2006).  Based on the success of this book, Wiley Publishers invited Ms. Glaser and Dr. Lavin to be the offical For Dummies authors for their reference book on sleep for young children: Baby and Toddler Sleep Solutions for Dummies.

And, more recently, their parenting advice has been made available on-line via the Who's the Boss Parenting Academy at www.whosthebossparentingacademy.com.  There, the philosophy and specific guidance first developed in 1994 and published in 2006 are available to anyone.

So it is with great pleasure that we read in the NY Times of May 23, 2016 that studies have demonstrated that our approach to helping families achieve a full night of sleep are very safe, and only support the bond of child and parent.  A recent study was reported to find that this approach, now widely adopted under the name "sleep training," has no negative impact over time on the relationship of the baby and the parents.  Check iBt out:  http://well.blogs.nytimes.com/2016/05/24/sleep-training-shouldnt-make-parents-feel-guilty/?_r=0

We have known for nearly 25 years that if parents gently ask their 4 month-old, or older infant or child, to take care of their own sleep, they will always do a terrific job, much better than any parent or doctor could.  And we have known for a long time that when parents do turn the job of getting to sleep and getting back to sleep over to their child, it really works, and has for over 10,000 families we have worked with over the years.

So it is very nice to see our approach found to be, as we have seen all along, very supportive of parent-child relationships.

BOTTOM LINE

Sleep training, now the dominant approach to managing the sleep of your infant or young child, reflects the approach and technique first put forward by Ms. Glaser and Dr. Lavin in print in 2006, and now more recently available as an on-line course.  

Recent data supports this approach as effective and very safe for the relationship of the child with the parent.

To your health,

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Home Birth- The American Experience of Giving Birth at Home

Home Birth- 

The American Experience of Giving Birth at Home

All people are born, but how mothers give birth and where varies quite a bit from culture to culture and across time.  

Current American preferences heavily favor giving birth in the hospital, about 99% of all births in the US occur in a hospital.  Those that occur out of the hospital include births planned to deliver in the hospital but didn't make it in time, and deliveries that were planned to occur in the home of the mother.

In 2012, about 0.9% of all deliveries took place in the US, by plan, at home.

In the Netherlands, also in 2012, about 16% of all deliveries took place, by plan, at home.

And even in the US, the rate varies.  The state with the highest rate of home births is Oregon, where in 2012 and 2013, about 4% of women gave birth at home.

American Infrastructure for Home Birth

One reason home birth is less frequent in the US than the Netherlands is a vast difference in how babies are delivered at home in the Netherlands.  There, the person delivering the baby is a fully certified, highly trained professional, whose actions in delivering at a home are openly and highly coordinated with local medical centers.  The delivering professional is part of the community health professional structures.

This means that the professional delivering a baby at a Dutch home has highly developed and open contingency plans for the first sign of trouble.  The same approach takes place in Canada.  These plans strictly deny the option of a home birth to mothers who have complicated pregnancies (e.g., twins, breech presentation).  In Canada, about 25% of mothers attempting to deliver at home are easily transferred to a obstetric division in a hospital if any danger seems to be developing to mother or baby.  That number is 45% for first time mothers.

The delivering medical professional in Canada and the Netherlands has hospital privileges, and so can continue to care for mother if she delivers in the hospital.

The US is dramatically different.  Home births are frowned upon in the US.  Very few, if any, licensed obstetricians will support midwives delivering at home.  Very few certified nurse midwives who have hospital privileges, will deliver at home.   Home deliveries in the US take place nearly in secret, certainly without coordination with hospital systems.  The delivering professional is typically a certified professional midwife (CPM), which used to be called a lay midwife.  CPM's are only given legal permission to deliver in 28 states.  Many achieve CPM certification via correspondence courses and receive training by other CPM's.  In 2012, requirements were updated to require a high school diploma.  In contrast, the certified nurse midwife (CNM) is an advanced degree nurse who can legally deliver babies in all  50 states, has to achieve graduate school level schooling, with rigorous clinical training, and often must practice in collaboration with an obstetrician.

The real difference in the US comes down to this:  in Canada and Netherlands the midwife who delivers at home is fully integrated in the official medical system, can also deliver their patient in the hospital, and has a seamless connection to it.  In the US the midwife who delivers at home does so essentially separate from the medical system, unable to deliver the mother in the hospital, with no well-established two-way systems (hospital and midwife working together) in place to rapidly respond to a problem.   

Many of these issues are clearly presented in this NY Times article:

http://www.nytimes.com/2016/05/01/opinion/sunday/why-is-american-home-birth-so-dangerous.html?_r=1

Safety of Home Birth in the US

In the last issue of 2105, the world's leading medical journal, The New England Journal of Medicine, published as study of all births in the state of Oregon in 2012 and 2013, and asked, how did mothers and babies do if they planned to deliver at home v. planned to deliver in the hospital.

They compared groups' plans, because if you just look at those who actually delivered at home, you artificially exclude those who were going to deliver at home, but had to go to the hospital due to problems.

Now, it is important to note that there is a rate of death in the newborn period no matter where you deliver, in the very best of worlds, some tragic death still takes place. 

With that in mind, here are the numbers:

From 1970 through to today, despite the increased use of induction and C-section, the chance of a baby not living much past delivery has remained steady at 1 in a thousand (1:1000) births.

In 2012 and 2013, in Oregon, if you planned to deliver in a hospital, the chance of the baby not living to a week of age was 1.8:1000 (as time goes on, this number goes up, as we know, after 120 years it goes to 1000:1000).

 In 2012 and 2013, in Oregon, if you planned to deliver at home or at a birthing center out of a hospital, the chance of the baby not living to a week of age was 3.9:1000.

Births following the plan to deliver out of hospital births also carried higher risks of the baby suffering certain troubles, including need for a ventilator, blood transfusion, seizures.

At the same time, women planning to deliver out of the hospital experienced far fewer C-sections, induced labors, and episiotomies.

In this same issue of the Journal, a commentary by Dr. Michael Greene, Chief of Obstetrics, Massachusetts General Hospital, who I have known a long time, gives the above information is a very balanced and measured approach.  His last line is: "Ultimately, women's choices for place of delivery will be determined by the extent of their tolerance for risk and which risks they want to avoid."  

He is referring to the risk of the baby coming to some harm versus the risk of the mother experiencing obstetric procedures.

BOTTOM LINES

1.  Home birth in the US would benefit tremendously from full integration with the medical system.  This would allow fully trained midwives to participate with full backing of obstetricians, and the development of full communications with hospitals to make transfer to the medical setting far easier and more integrated.  In countries where this is the reality, no difference in newborn survival at home v. hospital is seen.

2.  Until that happens, giving birth at home does more than double the chance of a baby not living to a week of age.  

3.  It is also true that planning to give birth at home sharply reduces the chance the mother will have a C-section, induced labor, or episiotomy.

4.  Wherever one delivers, the baby needs a shot of Vitamin K soon after birth.  About 1:1000 babies who do not receive this very helpful aide will actually experience serious bleeding in their brain.  The Vitamin K shot provides the needed substance to help the baby make normal clotting factors.

Very importantly, we at Advanced Pediatrics are very happy to work with all parents, whatever their plans, to discuss what is an important, and often complex, decision.

To your health,

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Your Chance to Offer a Good Word

Dear Families,

As many of you know, Advanced Pediatrics is updating our look and feel.

Most of you have seen our renovated office.  Now we are working on our new website.

We thought it would be nice to feature some of your stories, and so we are now asking for you to send in testimonials to info@advancedped.com

We are seeking stories and testimonials from families covering three broad ranges of experiences.

These would include testimonials regarding day-to-day success stories such as getting prompt service, seeing who you want to see, having issues addressed.  And we would also great appreciate testimonials families might have about help we have offered that has made a difference in your child and/or family's life.

Once again we ask with tremendous gratitude to all of you for the trust you have put in us to be your infant, child, adolescent, and family's pediatricians.

With my best,

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Antibiotics- What Goes Wrong if not Used Properly

Antibiotics:

What Goes Wrong if not Used Properly

Antibiotics are the most popular prescriptions but the most poorly understood.

They do tremendous good, but when used inappropriately, they cause much more harm than people know.

And, by people we mean families and doctors.

In fact, so many doctors prescribe so many antibiotics inappropriately that the CDC a few years ago began looking into restricting the ability of doctors to prescribe them.

Most of us appreciate the tremendous power of antibiotics to help, but what is the story of how they can hurt?

What is an antibiotic?

An antibiotic is a medication that can kill bacteria without killing our own human cells.

The key word in that sentence is the word bacteria.  

Antibiotics kill bacteria, not other germs such as viruses, fungi, and parasites.

What is the difference between bacteria and other germs?

There are four types of germs that cause infections:  Bacteria, fungi, parasites, and viruses

Bacteria

Bacteria are single-celled organisms that live by eating nutrients in their environment, and in the case of bacteria that cause infections in us, by eating our cells.   When bacteria infect, their eating usually creates pus.  Bacterial infections not only feature pus, but higher fevers, and often more serious and feared infections, such as bacterial pneumonia, bacterial meningitis, and various abscesses.   

The most common and minor bacterial infections are the very familiar and usually harmless strep throat and ear infection.  Bacteria also cause urinary tract infections which also tend to be harmless.

Bacteria are killed by antibiotics, and can cure these infections.

Fungi

Fungi are also single-celled organisms but can grow in complex branching forms that join many fungal cells together.  Healthy people do not get internal fungal infections normally.  For most healthy people the only fungal infections are surface infections and include ringworm, yeast infections, and oral yeast infections in infants (thrush).  These infections involve the fungi only eating dead cells that line the outer levels of the skin and mouth.  They create scaly rashes, fuzzy white plaques in babies' mouths, red rashes in the diaper area, but not pus.

Fungi are not killed by antibiotics, and antibiotics cannot cure these infections.

But there are other medications, related to antibiotics, called anti-fungals that can cure these infections.

Parasites

Parasites are single-celled organisms that are more complex cells.  Like fungi, in healthy people, most parasitic infections take place on the outside of the body.  Keep in mind the inside hollow tube of our gut is outside our body.  Think about what happens if you swallow a penny, you pass it through your gut and poop it out, and so it never enters your body.   The most common parasites that cause infections are lice, pinworms, and giardia.  Each of these never really enter our body, our bloodstream.

Parasites are not killed by antibiotics, and antibiotics cannot cure these infections.

But there are other medications, related to antibiotics, called anti-parasitics that can cure these infections.

Viruses

Viruses are a totally different type of germ than any of the above three.  All the germs listed above are made our of different types of cells that live on their own, and live by eating material and/or cells around them.  Like all animals and plants they eat, reproduce, and eat and reproduce.

But viruses are so, so different.   A virus is a bit of genetic material inside a coating of protein.  That's it.  Viruses never eat.  And without a cell to infect, they cannot reproduce, ever.

The way viruses work is very simple, and is described as a two step process:

1.  Their protein coat contains codes that allow the virus to enter their target cell.

2.  Once they have cracked the code to get in, the genetic material in the virus takes over the DNA in the target cell, forcing it to make all new viruses, and tons of them.   

Together, these two steps lead one virus to create millions more, usually popping the cell and leading to millions more cells getting infected and destroyed.

That's the incredible biology of viruses.  But there are some other very important points to be made about them:

1.  In infants, children, adolescents, and young adults, viruses cause the overwhelming majority of infections. 

Think about the main viral infections we experience:  colds, flus, stomach flus, viral fevers and rashes.  About 70-90% of all fevers in childhood are due to viruses.

2.  These most common viral infections are miserable, but harmless.  Everyone gets viral infections, no exceptions.  And in a healthy population of young people, such as we have in the US, viral infections come and go without causing any permanent harm.  Consider the most common viral infection- the common cold.  If it does not lead to any complications, such as bacterial pneumonia, and remains a cold, essentially everyone recovers without any harm long term at all.

3.  All viral infections often cause aches, pains, fever, and lots of inflammation and mucus, but not pus.  Again think about viral colds, they cause aches, pains, fever, and lots of mucus, but no pus.  The runny nose always starts with clear mucus and ends with yellow and white mucus, but there is no pus.

And, in regard to antibiotics, they are useless against viruses, they simply do not kill them, or even slow them down.  They do nothing to viruses or the infections they cause.

Of all the germs listed above, we have the fewest medications for viruses.  A tiny number of viruses have some medications that can kill them, such as the antiviral medication acyclovir to kill the herpes virus.  There are no such medications whatsoever that have any impact on the viruses that cause the common cold and stomach flus.  There are some medications that kill the influenza virus, but they have limited impact and can cause seizures in children.

But when it comes to the antibiotics, they have no impact on viruses at all.

What's the big deal about using an antibiotic in a viral infection?

The big deal is that right now, about 23,000 Americans die every year from the use of antibiotics used for viral infections.   This is comparable to the number of Americans who die every year from guns and cars (about 30,000 each).

Many people wonder, it's one thing to use an antibiotic for a viral infection knowing it won't work.  But how could using an antibiotic that doesn't work lead to harm, particularly someone dying?

The way that happens is explained in one word:  resistance.

This brings us back to bacteria.  Every time we use an antibiotic, remember that's a medicine whose only purpose is to kill bacteria, the clever bacteria get another chance to find a way to neutralize the antibiotic.

Consider what was once the most common antibiotic ever used:  penicillin.   After many years of use, all but one bacteria have figured out how to not be killed by penicillin.   The only exception is the strep germ of strep throat fame, it has never failed to be killed by penicillin, but so many bacteria in our mouths neutralize penicillin, that the strep germ can at times be protected.

So each use of antibiotics gives bacteria a chance to evolve a way to neutralize them.   The other part of the story of resistance comes in another key word: volume.

If doctors and families only used antibiotics to kill viruses a total of once a year, bacteria could learn to neutralize them, but it would be extremely unlikely.  But consider of millions of people take antibiotics every day when they only have a viral infection, now unlikely turns to certain.   And that is precisely what happens.

So many millions of people have colds and so many of them get antibiotics, that bacteria have millions and millions of chances to learn resistance, chances they should never have.

The result is that we are experiencing a dramatic epidemic of bacteria learning to laugh at all our antibiotics, creating germs that can infect us that cannot be killed or cured, opening the door to a huge rise in dangerous infections that cannot be treated.  This is how use of antibiotics for colds is right now killing 23,000 of us a year.

The example of viral pink eye

Few completely harmless infections cause more fear and anxiety than viral pink eye.   Pink eye is condition in which our eyes get red, make extra tear or mucus, and become uncomfortable.  There are three main causes of pink eye:

1.  Viral pink eye- this is exceedingly common during cold season.  Viral pink eye is in fact, the manifestation of a cold in the eye.  Just like colds in the nose cause the lining of the nose to get swollen and sore, and make loads of mucus, colds in the eye cause the lining of the nose to turn red (hence "pink eye") and make lots of tears and mucus.   In the morning the mucus can accumulate from overnight and cause the eyes to be swollen shut and matted with dried mucus, but there is no pus. There is no drug that can help or treat viral pink eye.  Antibiotic eye drops have no impact on viral pink eye.

2.  Allergic pink eye- this is exceedingly common during allergy seasons.  Allergic pink eye is like hay fever in the nose.  In both cases there is itch and mucus.  Red, itchy eyes, with some mucus during allergy seasons associated with nasal hay fever troubles is most likely allergic pink eye.  This form is treatable with antihistamine, by oral route or eyedrop.

3.  Bacterial pink eye- this is the least common form of pink eye, and the only one with pus.  Bacterial pink eye causes lots of pus, not just mucus, to form, usually overflowing the eye.  It is the only form of pink eye that antibiotic eye drops do anything at all.

Now, here it gets very interesting and worrisome.  It has been determined that if we use topical antibiotics for children with a cold in the eye, we will be giving millions of people antibiotics that have no benefit, and it has been shown that very dangerous bacteria, like MRSA, start to appear.

MRSA is a form of a dangerous bacteria, Staph, that can no longer be killed easily with common, or most, antibiotics.  Now imagine, if doctors and families agree to the use of antibiotics for simple viral pink eye, the nation becomes exposed to potentially deadly bacteria.

BOTTOM LINES

1.  Antibiotics are medicines that kill bacteria.

2.  Antibiotics do not kill any viruses, cure no illnesses caused by viruses, help no one with a viral infection in any way.

3..  The vast majority of infections in infancy and childhood are caused by viruses, including pink eye.

4.   Not only is the use of antibiotics in viral infections useless, but it causes about 23,000 Americans to die every year for no reason aside from our misguided habits.

Putting it all together, this is why we at Advanced Pediatrics will always let you know when it is clear that your child's infection is a virus, and will explain why use of antibiotics is not only not helpful, but could end up hurting someone we all care about.  We also appreciate that when any child is ill, the need for a solution is urgent and pressing, but we know that families ultimately want to avoid treatments that do no good and cause real harm.  Perhaps one day we will have a medicine that kills and cures the common viruses, safely and effectively.

To your health, 

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

News, Some Change, An Appreciation

News, Some Change, An Appreciation

Dear Families,

As many know, we have approached the practice of pediatrics with the relationship to families as the central core of what we do.   Over the years, this has meant many families have formed very close working relationships with our providers.  And you should know we also enjoy working together as well.

So it is with some real sadness that we are informing our Advanced Pediatrics family that Kelley Muldoon Rieger is going to be retiring from Advanced Pediatrics to spend more time with her family.

At the same time, we are happy for Kelley that she can have this special time together while her children are still young.   Kelley has let us know that her last day in the office will be May 20 of this year.

That is the news.

The change of course will be that Kelley will no longer be in the office caring for your children.  Dr. Hertzer and I will be available for all such care starting once Kelley leaves.  We will continue to offer the same level of service, including availability for same day appointments.  

The only other change that you might experience will be during times of scheduling health supervision visits (check-ups) around the time that camps, sports, or school start.  That has always been a time when appointment requests tend to bunch together causing us to only able to offer appointments some days after the requested time.  But there are several solutions to this potential challenge:

1.  The best idea is to schedule your child's annual health supervision visit (check-up) around their birthday, this avoids trying to book this sort of appointment on the day before school when so many others find themselves having to do who did not use this strategy.

2.  Talk to our office to enroll in our online services program called Healow.  Get a username and password, and go online to request appointments well in advanced.

That is the change.

As Kelley prepares to leave, we want to offer much deserved appreciation.   Ms. Muldoon Rieger came to Advanced Pediatrics before we opened, as our account representative for our first electronic medical record software, in 2002.   She and her husband had recently moved to Cleveland, and the various interests aligned, as we were looking to hire a nurse practitioner and Kelley was interested in practicing pediatrics.   And so Kelley joined Advanced Pediatrics at its very inception and has been here since.

Kelley has brought a refreshing, upbeat, sharp, caring stance to her practice of medicine.  This has been in strong evidence every day over the last 13 years.   Her clinical acumen has been exceptional, many families have been the beneficiary of her expertise and clear eye.  In practice, we are called upon to evaluate large numbers of situations and not miss the one of these many that indicates a serious problem.  Over the years, many families have come to experience Kelley's outstanding ability to do just that, to know something is different, that something needs further evaluation.   And in essentially every such circumstance, Kelley has been right and found a problem that was important to address.  Many children and families have benefited from her abilities.

Just as important as her medical expertise has been her total commitment to care.  To make sure families were comfortable, that they understood, that their issues were listened to and addressed.

I have always valued the sound of laughter coming from Kelley and the families she is seeing in her rooms.

Putting it all together, I want to thank Kelley for her care of all of you over the years.  There are few doctors or nurses I know who have done, or could have done a better job.   We will miss Kelley working here, and wish only the best going forward, and say so with a tremendous amount of gratitude.

And, as I know Kelley would agree, Dr. Hertzer and I remain here, able to carry on just these same qualities so that Advanced Pediatrics will continue the same level and quality of care you have come to expect from us.

To your health,

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

On Emerging Words and Sentences- the Power of Language

On Emerging Words and Sentences- 

The Power of Language

This is the next in a series of musings inspired by visits with our wonderful granddaughter, Evie, who lives in Hong Kong.  

The occasion this is an amazing event in our family's life, the wedding of our daughter, Hannah in May of 2016.   This great celebration brought the whole family together, including our son, and his family, which means Evie.  I will note that the wedding was an extraordinary moment.  Of all family events, weddings are one of my favorites, it is a moment of incredible creation through our own actions.   After all, no one chooses their parents, and few choose their children, but every couple chooses each other, and creates a new relationship, and often, family, from that choice.  We are very lucky that our new son-in-law is a terrific person who cares for Hannah so well, and who we care for very much as well.

During the week after the wedding, Evie's parents took a break, and we took Evie home with us for most of a week.  It was a powerful and wonderful experience spending 4 days with our 21 month old granddaughter, we really got to know her ways, her daily rhythms, who she is.  It was nothing but pure delight!

She turns out to be a very witty and positive young girl, who is consumed with songs and stories.  She also uses the word yes much more than I would expect.  

In these posts on Evie, I like to share whatever few insights I gain observing her at various ages.   The main experience that moved me this time, again at age 21 months, was the power of emerging language.   Last time we were with her, her ability to understand what people say was emerging.  This time, her ability to tell us in complex sentences what she is thinking is emerging.

I suppose the first thing to share is the power of song in learning to say something.  Music is a totally different production of the mind from words, and seems to be a much older part of our minds.  There is evidence that some human-like species, the hominin species like Homo habilis or erectus, made bone flutes that even today can make in-tune music, a million years before we Homo sapiens were evolved, long before the first word was spoken.  We also know at the the end of life, songs we know are remembered long after many facts fade.

So it is very intriguing to watch Evie start her life of talking with songs.  She loves songs, especially songs with gestures and strong emotion, such as "The Wheels of the Bus,"  "The Itsy Bitsy Spider,"  "Little Boy Blue,"  "Open-Shut Them."  To name just a few.  We have watched her pick up the idea of the song, and even most of the lyrics, after 2-3 rounds of singing them.  Once she knows the words, she loves singing them together with us, over, and over, and over.

The tune is quickly recognized and picked up, then when one adds words, you have easy access to telling a whole story.  Singing songs, like reading familiar books, opens a path to telling a story.

But telling a story turns out to go well beyond telling that story.  Telling a story allows one to create one's own story.  And this is the next thing we got to see with our time with Evie.  Evie spends most of every moment when awake in the frame of a story.  She creates a narrative that explains to herself and others, what she is doing and what she is thinking.   

Her stories organize her ability to tell people her thoughts, but they also organize what her own thoughts are.

Of course, this is a fact for all of us.  Give it a try, try to have a thought unconnected to any story or narrative.  It is likely next to impossible to have a thought that is not part of a context, a story.

At our age, our words come pouring out, like in this post, a mile a minute, and our words achieve so many ends, but when spoken language first emerges, at any age, but typically between ages 1 and 3, we see the power of a story in full view.   

And that is just where Evie is at, she is moving from understanding what we are saying, to crafting words to tell us what she is thinking, and linking them into sentences that do indeed tell us what we are thinking.

How powerful, how delightful, and what a privilege all grandparents and parents have, to watch their children and grandchildren's language emerge, and at every step to see just how powerful language is, it's not just what we say and think, it reveals how we think.

We love our time with Evie, and it is a great pleasure to share some of these moments with all of you.

To your health,
Dr. Arthur Lavin  

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