Anticipatory Guidance for Toddler and Pre-Schoolers vs. Parental Wellbeing

I’ve been told that for those who foresee a career in medicine, few aspiring healers actually go on to choose the specialty that they originally envisioned for themselves. I’ve known since I was 5 years old that I wanted to take care of children, as documented in my kindergarten “All About Me” book. I clearly proclaim in the book’s crayon written forward that I had plans to become a kindergarten teacher or a baby doctor. As I became older I was fascinated by the idea that my sister was premature and that, when she was born, she was small enough to fit into the palm of your hand; she had spent her early months in a plastic box.

Eventually, I learned that the baby doctors who took care of the babies in the plastic boxes or incubators were called pediatricians. Then I was excited to learn that they were in fact, pediatricians who specialized in the field of neonatal-perinatal medicine, neonatologists for short. And so, my fate was sealed. I was going to be a neonatologist. Along the way, I mentored kids, participated in story time at the library, played doctor with my dolls, and volunteered in the nursery. During medical school, I researched childhood developmental patterns, developed parental resources to ameliorate stress, worked at the CDC and studied the effects of childhood lead poisoning. During residency, I realized that although I loved the NICU I really loved follow-up of NICU babies and was blessed to run the follow up clinic for several years. Is there anything better than empowering a parent to realize that they can truly parent; that they are capable of being everything their child needs?! I think not…it’s the best feeling in the world, and I consider myself a parent advocate first and a pediatrician second.

But then I had my own children and realized a couple of things.

I had my first child during my neonatology fellowship. As a new mother, I enjoyed every other night call at Parkland Hospital, which at the time boasted one of the busiest delivery services in the United States. My hubby and I tag-teamed and did the best we could, but it was hard, even with our resources. I realized that although I had encouraged many moms that breast is best, I was unable to maintain my milk supply during my training as a fellow; I had to stop at 6 months. I realized that, although I shared with my families that their babies should sleep on their backs and not their tummies, my baby preferred her tummy. My baby had colic. My baby was very gassy, and it was a bit challenging to let her cry it out. How many mothers had I encouraged to let the baby cry it out? It was also a bit challenging to walk around all night rocking her. Sleep deprivation became my norm. I knew she wasn’t supposed to sleep in our bed, but she found herself in our bed more often than not. I wasn’t proud of this. I knew she wasn’t supposed to have her pacifier beyond the first year, but I also knew that there were some battles I didn’t have the energy to fight. So, yes, she had it until pre-K. Today, at 19, she has perfect teeth and never required braces.

I remember feeling like a hypocrite. Being calm, reassuring and telling parents that their feelings were normal. That they would manage their routine. That yes mommy should just keep pumping. That yes, the baby should always stay on his or her back. That yes, they should hasten to get rid of the pacifier before it’s too late and if possible don’t even start! (This was of course before the SID data in support of pacifier use.) I struggled with advising parents during the day and barely meeting those anticipatory guidelines during the night. I was in fact Super Doc with all the answers during the day and exhausted mommy doing my best to keep up at as soon as my work day ended. Hubby and I often smile now that our daughter was such a good baby while we were trying to figure out how to be parents, and be husband and wife, and manage our career and household.

Two years later, in my last year of fellowship, we were blessed to have our second child, a boy. I was an attending now. We had more resources. Hubby and I had figured out how to make it work, and we did. But what if we hadn’t? What of those parents who are still trying to figure it out? What if you do have to make some concessions along the way. How can we more realistically support parents? Where are the Ages and Stages that meet you families in the middle? Can we support children without supporting parents?

Fast-forward 15 years. Our kids are 17 and 19 and appear to be doing well. I have 20+ years of experience under my belt. I have taken and renewed my Neonatal and Pediatric Boards twice. I keep up with the literature. I am keenly aware of the Ages and Stages Guidelines, but I have never forgotten what a desperate time new parenthood was for us! We recently kept our great nieces, ages 18 months and four years, for one week. What a reality check!! Again, I learned a lot.

I had forgotten how much energy is required to keep up with a toddler and a pre-schooler. As I relearned from my nieces, after a full day either in the home or out of the home, you might find yourself violating the screen time guidelines a time or two. Because you need a moment. Because dinner has to be prepared. Because life. And we can’t beat up parents about that.

And let’s not forget about the guidelines for routines. Routines are so important for children. We tried with our nieces. We tried to have a set dinner time, a set breakfast time, a set lunch time. We tried to limit screen time. We tried to have a set bath time. We tried to have a set bed time…oh, and we tried to put them in their own beds as well. This was at best a work in progress and at worst a disaster!!

Sometimes they were in bed by 9, but most of the time they were not! Bath time was great fun, but never at the same time. Story time was a huge hit, but never at the same time. Even bedtime often violated screen time, as movies were quickly revealed to be the way we all went to sleep. But what about reading? Reading is fundamental, I wholeheartedly agree!! Did we read books? Yes, we read books; the kids loved them. But, after several books, we watched Beauty and the Beast (their favorite) over and over and over. I felt like I received a pediatrics parenting demerit each time!

Lastly, meals. Yes, children should have fresh vegetables. No sugary sweets. Healthy alternatives. I agree! I say it every day to my patients. But to provide healthy alternatives to your children, you must be providing healthy alternatives to yourself. We learned that we eat out a lot. We had to force ourselves to make sure the girls were getting healthy alternatives, and they loved those alternatives, often saying, “Yay real food tonight.” But, this was a hard adjustment for us, even with our resources and 20 years of parenting experience. Of course, we thoroughly enjoyed our time with our great nieces, but I wondered what do young families do who are overwhelmed? Families who need resources and easy alternatives? What about single parents? How much anticipatory guidance have I given to families who are overwhelmed, who are stressed, who are doing the best they can, but even their best doesn’t meet the guidelines for best parenting practices?

I will of course continue to encourage and endorse the AAP Guidelines for effective parenting and positive child development. But, I will also remember to ask mom or dad how they are doing. Sometimes the best guidance is “It’s okay.” It really is okay. Exhale…and try again tomorrow. And then I tell myself the same thing. It will be a year before we keep our great nieces again. They will be 2 and 5; this time, we will be ready!