Growing Clientele – Pediatricians Adjust to a Changing Landscape

“Thirty years ago, pediatricians told mothers what to do; today, we give advice, but we also have true conversations. We are the experts in medicine, but parents are the experts on their child,” said Dr. Laura Koenigs, interim chair of the Department of Pediatrics at Baystate Children’s Hospital and a pediatrician who specializes in adolescent medicine. “It’s a change that has been good.”

Dr. John O’Reilly agrees. “Most of what happens to children takes place in the home,” said the general practitioner at Baystate Pediatric Associates and assistant professor at Tufts University. “The environment a child lives in has a profound impact on their health, and there are many areas to deal with in addition to medical care. Pediatrics is not just about giving shots. It’s only a small part of what we do.”

Indeed, the relationships that pediatricians form with families are critical to a child’s health, and Dr. Robert Leavitt says knowledge about a family’s history can help pinpoint concerns that may not be overtly expressed. For example, if a child has a persistent cough and the pediatrician knows their grandparent died of lung cancer that started with a cough, it allows them to alleviate fear that the parents may be harboring. “The more we know, the easier it is to help,” he said, adding that he opened Meadows Pediatrics, L.C. in Longmeadow in 1994 after working for Baystate Medical Center and a practice affiliated with the University of Rochester.

Many pediatricians see patients from birth through age 18, while others care for them until they graduate from college or are in their early 20s. “Young adults don’t always know where they will be living, and it can be difficult for them to find a primary-care doctor,” Koenigs explained.

But whether they are dealing with infants or young adults, education plays a critical role in their work as medical advances in areas such as brain development yield new information about topics ranging from the effects of screen time on children (see related story, page 14) to the ways in which poverty impacts health. In addition, doctors discuss developmental and behavioral issues that can be hard to deal with.

“Parenting is not a natural skill. It’s complex, difficult, and stressful, and different kids have different personalities that can be seen from day one. So we talk to parents about appropriate discipline, routines, and other things they are concerned about,” O’Reilly said. “Sometimes we can put a spin on problems that makes it easier for them to deal with. For example, when we explain that a tantrum is a way of showing independence, it helps parents get through the terrible twos.”

“Things can be a big problem for them that would not bother adults. If an adult gets the respiratory syncitial virus, they will usually feel like they have a cold. But if a child under age 2 has the virus, they can develop bronchiolitis and may need to be hospitalized,” he said, explaining how it affects their tiny airways. “But kids are a lot of fun and are pretty healthy. They usually get better if they are sick, while adults tend to have more chronic problems and may have self-inflicted conditions.”

Koenigs concurs, and says children are a joy to work with. “I love what I do. It’s interesting, and it keeps me young. Kids have a wide-open outlook on life that makes you look at the world differently.”

One problem pediatricians face is educating parents who don’t want their child to be immunized against disease.

“Since we haven’t seen most of the diseases we vaccinate against for a very long time, people forget how horrible they are. They don’t remember tetanus and diphtheria or understand that a child can die from chicken pox or pertussis [whooping cough],” Koenigs said.

“Anyone who has seen these diseases would never want their child to get them, and with the exception of smallpox, they are all on the rise,” she went on, adding that a child with measles was treated at Baystate Medical Center last year, and a number of players in the National Hockey League were recently diagnosed with mumps.

Leavitt agrees. “These diseases are preventable, and parents who refuse the vaccinations are not making decisions based on scientific facts,” he said, citing the now-disgraced British doctor Andrew Wakefield, whose fraudulent study suggesting a link between vaccines and autism has contributed to plummeting vaccination rates.

O’Reilly agrees that immunizations are more important than ever as the world becomes more interconnected.

“A case of measles in Ireland can result in cases in Massachusetts due to travel between the countries, and parents who refuse to get their children immunized are putting others at risk,” he said. “But if they read scary stories on the Internet that are not scientifically based, it becomes difficult to have a conversation, as you are dealing with fear instead of facts.”

Koenigs said liberal state laws in Massachusetts also play a role in the problem. Although children are required to get certain immunizations before they can attend school, if parents sign a form saying they object to them, the requirement is waived.

Another pressing issue called ‘toxic stress’ can range from domestic violence to child abuse or a contentious divorce with ongoing conflict. The Center on the Developing Child at Harvard University says prolonged activation of stress-response systems in the body (especially the brain) have damaging effects on learning, behavior, and health across a person’s lifespan, but the effects often don’t show up until adulthood.

 “We don’t understand why this happens, but studies show there is a direct correlation between toxic stress in childhood and high blood pressure, strokes, and obesity in adults. It’s also hard on the heart, even if children appear to have adjusted to the situation,” Koenigs said.

O’Reilly cited other, equally important research on the brain. “Some studies show that language develops rapidly during the first year of life, and the more words a child hears during that time period, the better they do in elementary school,” he told HCN. “We do simple things in our practice such as giving every baby a book and explaining to parents that sitting with a child and reading not only helps with language development, but also helps them to focus, improves their fine motor skills as they turn the pages, and helps them with visual tracking and hearing. Many people think that education happens when children get to kindergarten, but parents can do things to build their child’s brains long before that.”

Diet is another issue that can certainly impact health, and Koenigs asks parents if they have enough food to last each month, because many don’t. “Nutrition is a problem for a lot of children who are not getting enough food or the right kind of food,” she said.

Play is also critical to development, and doctors are concerned that many children are falling short in this arena. “Children need to burn off energy, and kids are active in their natural state, which helps them to build muscle and focus better in school,” Koenigs said. “But many schools have gotten rid of recess.”

She added that exercise is also important for teens, and activities such as swimming, kayaking, hiking, bicycling, and kickboxing may interest them.

“If a child is very sedentary, it makes it difficult for them to become physically active when they get older. Exercise and eating habits are often established when children are young, and a lot of that depends on the parents,” Leavitt said, acknowledging that socioeconomic factors play into the equation, and some parents don’t live in neighborhoods where it is safe to let their children play outside.

Gun safety is another problem that affects children’s safety. “Seven to eight children in this country die every day from gunshot wounds,” Koenigs said. “You cannot educate children about guns. They need to be locked up because children are naturally curious.”

Overall, the relationship that parents form with their child’s pediatrician plays a critical role in whether they feel free to share concerns about their personal situations. For example, O’Reilly says many mothers suffer from postpartum depression, and it’s important for them to share how they are feeling because it can affect a baby’s development.

“If a baby is cooing and trying to get an adult to engage in an interaction and the parent is depressed, they may not notice or may have an abnormal response,” he said. “It’s also important for people to tell us if they don’t have enough food or money because things that happen in early childhood can lead to chronic disease in adulthood.”

He added that pediatricians can make referrals and help families access help, which ranges from family therapy to community support groups to early-intervention programs for children who are developmentally delayed.

Springfield suffers from a high rate of asthma, and housing in poverty-stricken neighborhoods can be related to the disease, as children can develop reactions to dust mites and become sensitized to antigens produced from exposure to cockroach droppings.

“Baystate has a program that sends home health workers to people’s apartments to help them improve the environment,” O’Reilly said. “Being a pediatrician involves far more than medicine. We have to do many other things. We are educators, but we are also coaches.”

Leavitt says partnerships mean shared responsibility, and doctors take parents’ requests seriously. “We used to routinely treat ear infections with antibiotics. If it’s a toss-up and the parent really wants the antibiotic, we can give it to them unless it is medically inappropriate,” he said, citing just one example. “But if you have developed a good relationship with the parents, they are more likely to agree to a let’s-wait-and-see approach.”

Trust also comes into play when patients reach their teenage years. As children mature, pediatricians typically talk to them alone to provide them with the freedom they need to ask questions.

“It’s my job to help them navigate their way through adolescence and give them factual advice,” Koenigs said, explaining that, unless it becomes clear that someone is hurting them or they are in danger of hurting themselves or another person, these conversations are kept confidential. “Our job is not to drive a wedge between them and their parents. We are simply another link in their support system.”

Leavitt concurs, and says teens have told him they are depressed. “We see a lot of mental-health issues in teens. There is a lot of peer pressure in middle and high school, and as their social world becomes more complex, it can lead to anxiety or depression.”

Local pediatricians say they enjoy watching their patients mature. “We get excited about helping children get a good start in life and watching them grow through good times and bad,” Koenigs said.

Leavitt agreed. “We get to see how proud their parents are of their accomplishments. Plus, it’s rewarding to see medical problems get resolved or watch a child overcome challenges. It’s also rewarding to watch kids graduate from our practice and return to us with their own kids or go out into the world and do big things,” he said.

But the road to adulthood contains many roadblocks, and parents bring a variety of issues to the examining table.

“Being a doctor is like gardening; we plant seeds to weed out things that will be detrimental and help parents to make good choices,” O’Reilly said. “Sometimes being a pediatrician is pure medicine, and sometimes it’s purely behavioral. But our goal is help families so their children grow into healthy adults.”