Category Archives: Physician Life

The Runt of my Litter. Why I Worry About my Smallest Child and When You Should Worry about Yours.

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CharlottesWebEvery day in the office at least one parent expresses concern over their smallest child: “His siblings were so much bigger at this age”; “Why is she sick all the time?”.

I can completely relate to their concerns. My 4 year old daughter is a runt1. Like Wilbur the pig2,3, she is sweet and brilliant, but small and often sickly. My husband and I are both tall, athletic people. Her sister has always been in the 95th percentile for her height and weight. Little E is taller than average, but she is scrawny, and she gets sick… a lot. Her sister didn’t have a cold until she was 2 years old. E had her first cold at a few weeks of life and seemed to be sick constantly for her first 3 years.

Why do I worry? Since I first entered medical school 18 years ago I have studied everything that can go right with a child’s health and everything that can go wrong. I have seen innumerable children who have suffered from accidents, cancer, infections, genetic disorders, and autoimmune diseases. When I was in training we used to say “the sweeter the child, the more horrific the diagnosis will be”. There was no truth in our statement. It was just a reaction to the heartbreak we felt; time after time we had to share devastating news about a child to the family that cherished him.

Unfortunately I have kept that superstition with me. My little E is a cup-half-full kind of girl. She dances around the house singing “Let It Go”, yells “wheeeee” the whole time she is flying down the trail on her bike, and shows more determination and grit than almost any child or adult I know. She is also prone to covering me with thousands of kisses and 10 second bear hugs on a daily basis. I have tears in my eyes when I write this because my overwhelming love and admiration for this child is matched by my overwhelming fear that something bad will happen to her. I try to reassure myself by remembering that many of my friends, and parents I see in the office, share my neurosis about their littlest child.

So when do we really need to worry?

  1. Is my child continuing to grow? Your child may be in the 3rd or 30th percentile on her growth curve. What really matters is if she is continuing to follow that percentile (normal) or if she is continuing to drop off the curve (concerning).
  2. Is my child reaching his developmental milestones appropriately (or is he doing well academically)? Check here for more information on developmental milestones.
  3. Does my child get frequent infections requiring antibiotics or hospitalizations? Frequent ear infections in the first year of life are often due to anatomy (small, flat eustachian tubes that don’t drain the middle ear space well), but frequent ear infections are unusual after the age of 2. Recurring bacterial pneumonia, frequent skin infections, or blood infections are more concerning for an immune deficiency.
  4. Does my child have bloody stools or frequent cramping and diarrhea? These can be signs of inflammatory bowel disease or celiac disease.

So how do you protect your runt? Fortunately there are a few great things you can do to keep your children healthier: good hand washing, proper nutrition, consistent sleep schedules, limiting screen/TV time, regular exercise, and vaccines. We do all of these things in our home but my baby still get sick. If your child is in daycare or preschool (or his older sibling attends school) then he may get 10-12 viral respiratory infections per year. Exposure to second-hand smoke will also significantly increase his risk of frequent infections.

Thankfully now that E is 4 years old, her illnesses are less frequent and less severe. Hopefully her physical composition will eventually match her emotional one. In the meantime I will still snuggle up next to her when she has a fever, and I will hold her all night when she has a cough. It makes us both feel better.

1. runt (definition from

– an animal that is small or stunted as compared with others of its kind.

– the smallest or weakest of a litter, especially of pigs or puppies.

2. E.B. White, Charlotte’s Web, (New York: Harper and Bros, 1952).

3. No children or animals were harmed in the writing of this post. Both Wilbur and my 4 year old can’t read yet. If little E does read this in the future I am fairly certain she will forgive her mommy for calling her a “runt”.

How to Make the Most of your Visit with the Pediatrician

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This is a guest blog from Sheila Cason, MD. It was previously published on her site Dr. Cason is a photographer, pediatrician, and mother of three. I have great respect for her advice and incredibly compassionate nature.

Photo by Brendan Riley, Flickr Creative Commons

Photo by Brendan Riley, Flickr Creative Commons

Whew! The morning is over and I’m at lunch, preparing for a busy afternoon.

With the ever increasing time crunch, pediatricians are forced to see more patients in less time. Often we are only given 10-15 minutes to get the history, do an exam, make a diagnosis, formulate a plan and then explain the directions to the family.

This may be fine if the chief complaint is ear pain. But what if it’s chronic abdominal pain? Or a seizure? Then it’s even more important to streamline the visit so we can help your child and you get some answers.

Here are some simple ways to make your visit go smoother and get what you need:

1. First off let me know if you are running late for another appointment. I try not to run late but it’s ineveitable sometimes. There have been times when I go into a room and the family is seething! It seems they missed an incredibly important meeting. If I can I will try to adjust the schedule and see you faster. Or I’ll just cut to the nitty gritty and get you out quickly.

2. Let your doctor know what you really want. If you really want antibiotics, you’re going to be mad when you spent all that time and didn’t get it. Let them know. Often I’ll compromise. If it’s viral and they really don’t need the antibiotics, I let them know. But if it’s a cold and it has been over a week and a half and it’s tough for them to return for a recheck, then I may give them a script to take with them. I give instructions to start only if the cold hasn’t resolved by two weeks. Surprisingly most people don’t abuse this and both parties are happy.

3. Prepare your child: Tell your child where they are going. If they are old enough then let them know exactly what we are going to do. Encourage the young ones and don’t threaten shots if they don’t behave! It scares them to death and then I have to spend a lot of extra time coaxing them to let me even come close.

4.Know your history: Often I have a grandparent come in and not know anything. We have to guess and muddle through the history. This can take a lot of time. If you can’t be there, write a note or give me a number that I can call to ask you some pointed questions.

5. Don’t have the doctor tackle every thing on the same day. If your complaint is ear pain and a cold then talking about your child’s short stature might be better addressed at their well check or another appointment. You’re only going to get frustrated that the doc is rushing you.

6. If you’re still not happy let the doctor know. Some people still look at me at the end of the visit, all worried. I know something is up. Most parents who have a child with 1. Headache: worry it’s a tumor 2. Bruises: worry it’s leukemia 3. Fever and a cough: worry it’s pneumonia. Because parents have told me their fears I have learned what bothers them. I can anticipate this and talk with them about it.

I hope this helps. I think that most people who are frustrated that the doc didn’t spend a lot of time with them, didn’t get what they needed. Communication is key! A pediatrician’s number one priority is making sure your child is healthy and you’re happy!

Do you have ways that make your visit go smoother and you get what you need?

Do you have tips for the doctor that will make the visit go smoother?

Finally… the Bliss of a Sunday Don’t-Cram-in-the-Fun Day

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Photo by Linda Tanner, Flickr Creative Commons

Photo by Linda Tanner, Flickr Creative Commons

Today was one of those days when the whole world seemed to slow down. As I watched my children play I was acutely aware of how quickly they are changing, growing up so very fast.

For the past 13 years my husband and I worked full time, which for me also included every other weekend and holiday. It seemed like a reasonable schedule until my first daughter was born. My reasonable schedule then became hectic. When my second daughter was born 19 months later I found that my hectic schedule then became frantic. When I actually had a weekend off did we relax? Absolutely not. Weekends were precious and few so we crammed in a month’s worth of fun into every one. By 9AM we were usually on the hiking trails, biking trails, beach, playground, or Costco! We had done laundry, made beds and picked up toys before sprinting out the door with me screaming “get in the car” so we could have “fun”.

Thankfully, a year ago I finally hit the wall and apparently that wall knocked some sense into me.  I was overworked, overextended, and exhausted. I was missing Christmas mornings and leaving my sick children at home so that I could take care of someone else’s sicker child. I was passionate about my work, but it was time to find a replacement; preferably a doctor who didn’t have a 3 and 4 year old at home and a full-time working spouse. My children needed their mommy and I needed them. We decided to downsize our lives and cut back my work hours. It took almost a year to find my replacement at the hospital but I am finally home. Almost every day I take my kids to school, I get to pick them up 3 or 4 days a week, I am here at dinnertime, I am here to tuck them in at night, and I am finally home most weekends.

Despite all of these positive changes I have found my frenetic pace hard to break. Last week we finally slowed down. My kindergartener and preschooler were off for spring break and we headed south to visit a dear friend. My friend’s kids are a few years older than mine and it was eye opening to see how much changes in those few years. They don’t need you. I mean they need you, but not in that every second of the day baby/toddler/preschooler kind of way. Our girls immediately took off with her big girls and we only saw them for brief moments throughout the day. They painted their fingernails, learned to make lip gloss from YouTube videos, watched movies, and whined-cried-fought all of zero seconds! We relaxed, they relaxed, and we all slowed down.

We returned home a few days ago and today I feel like I just experienced my first real Sunday since we had kids. We did YOGA. Seriously people my husband and I, with the intermittent company of our daughters, actually did yoga in our living room. It took about 1 minute of yoga for me to pull a muscle but still… we did yoga! We then hung out until the late hour of 10:30AM and had a relaxing brunch with the aunties and grandmas, took a brief walk, and then came home to do almost nothing. I actually dug out the rubberband bracelet kit that Santa had brought my eldest and we made bracelets. I realize it is nowhere near Christmas anymore but we just hadn’t made the time. Later they played in the dirt while my husband and I read the paper on the front porch, we listened to music, cooked dinner together, and only “accomplished” 1 load of laundry. For a checklist kind of girl I have to say it was a little unnerving, but fabulous.

Don’t get me wrong there were still the occasional grumpy mommy moments, but overall it was a slow pace, snuggly kind of day. It was filled with laughter, smiles, a ridiculous number of kisses and hugs, and more “I love you Mommy”’s than we typically get on our hyperactive Sundays supposedly-fun-days. I can’t promise that this will be our new normal, but as I spend more time as mommy and less time as Doctor Raja I hope we discover the beauty in slowing down. My kindergartner chose Someday by Alison McGhee as her bedtime story tonight. She knows that I can’t get through it without my voice cracking and the tears flowing. I think she knew how special today was too.

A Pediatrician’s Survival Story: Remembering the Children

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pediatrician, pediatric residency, child death, infant death
Photo by geishaboy500, Flickr Creative Commons

I have just turned on my computer. It is midnight. I should be trying to sleep right now.

My 5 year old is sick and I am on call for the next few nights. Fortunately, my daughter should get better in a day or two. She needs Tylenol for her fever, mama’s love and time to kick this virus. But as I sat in bed holding her and waiting for her fever to break, the memories of other sick children started to come back. I completed my pediatric training over 10 years ago. I have repressed the memories of that time for so long now. Slowly, painfully they have started to come back. I lived a different life then, and it almost broke me.

I went into pediatrics because it was the only thing I was passionate about. When I entered medical school I was determined to do anything but pediatrics because I was so crazy about kids; I didn’t  think I could handle children hurting and dying every day. As I went through my rotations: emergency medicine, family medicine, obstetrics, surgery; I quickly learned that I was always drawn to the children. As it turns out I am amazingly calm under pressure, and the intensity of taking care of severely ill or injured children was something I was really good at. I ended up matching at my first choice program at the Children’s Hospital of the Kings Daughters in Virginia. Then my life took a detour.

My intern year I married and divorced. I married someone who was broken, but trying to put himself back together. And I was just starting to break. During that time I learned about how resilient a child can be, but I also saw the cruelty of cancer, AIDS, whooping cough, lupus, drownings, child abuse… The lack of sleep, unrelenting hours, and the pain and death around me took huge tolls on my mind and my body. I gained weight, I felt angry, I felt sad, I felt anxious, and I stopped crying my intern year. I finally ended up on antidepressants. On my rare weekend off I drank and danced until the wee hours of the morning. The day after residency ended I hopped on a plane to California. I left my memories and my medication behind, and my new life began. I was 30 years old.

It took a few days to start living and eating healthier. It took almost 2 years for the anxiety to dissipate. It was probably 3 years before I cried again.

My friends here don’t know the “before” me. I have never drank my sadness away here. I have never danced on a table to forget the pain. I am thankfully quite boring now. I run or hike almost every day. I am a loving mother and kind wife. I am a better daughter. I have thought for years about how much I disliked the person I became in training. But the truth was I was a survivor. I always have been and I always will be. I believe I am strong enough to let the memories come back now. I can picture some of the kids faces now. I can hear their words. I remember hugging them. But I still can’t picture the parent’s faces. As a mother there is a limit to how much pain I can process. The pain of a parent losing a child is too personal. Maybe that memory will come back in another decade. I kind of hope it doesn’t.

When I started writing this I thought I would share some of my memories of the tragedies I experienced within the walls of that hospital. It turns out that they are still too personal for me. It is enough for me to know that I remember now. And I am better now. As for the parents of those children lost, please know that everyone who cared for your child was forever changed by the experience. We loved them too. Pediatricians did not choose this field of medicine for money or for glory. We chose this field because we wanted to heal children. There is a part of us that breaks every time that we can not. I may not always remember, but I will ultimately never forget.

Previously published on, February 22, 2014

I want to thank my strong and compassionate friend Sheila Cason. She first wrote about her experiences on her blog,, years ago. Many of her memories were also my memories. I just wasn’t ready to face them yet.

I would also like to thank Dr. Nadia Wasylyshyn at the Children Hospital of the Kings Daughters. She was a great source of support for so many of us through those tough years. The high rates of depression and burnout are well documented for physicians in training. It is so important to find someone to talk to.