Friday, December 5, 2008

Finding a Size-Friendly Pediatrician

One topic that keeps getting requested in the comments is parenting as a fat person. That was on my to-do list anyhow, but the requests just moved up some of my plans for what to post and when. Believe me, this stuff is significantly on MY mind too.

I thought I'd start with the importance of finding a size-friendly pediatrician/family doctor.

Once you have that baby, then what? The pressure for limiting weight gain doesn't stop with pregnancy; once the baby is born, many docs measure that baby within an inch of its life and soon start getting concerned if your baby is larger than average or is gaining "too quickly." Soon the lectures and "suggestions" begin.

Obviously, all doctors are not created equal. Some pediatricians are truly wonderful and very supportive, regardless of size. We're not condemning all doctors by any means. But with all the new pressure on doctors about the "childhood obesity epidemic," many doctors are really ramping up the harassment factor if they even think your child might be larger than average.

Oftentimes, it goes back to the old assumption that if you are fat, you obviously overeat and/or eat the "wrong" foods, and therefore no doubt will be teaching that poor lifestyle to your child as well. So there may be extra lectures about "healthy" eating and exercise, extra measuring of the child, and extra monitoring for problems.

Any sign of the child being above the 85th percentile may be seen as having a fat (or an imminently fat) child, with pressure to keep that weight down. Weight loss and "fat camp" suggestions for older kids may even follow from some docs.

But often, the first signs of pressure come early, during breastfeeding.

Overfeeding and Breastfeeding Worries

Sometimes the "weight" pressure starts almost immediately. Doctors may be concerned that a fat parent will "overfeed" the baby, so sometimes there may be pressure not to nurse "too much"---to limit the baby to a certain number of minutes per breast, to space out feedings so as not to feed "too often," and to strictly avoid "comfort nursing" when the baby is upset or just tired.

This concern is a reflection of some doctors' lack of knowledge about breastfeeding. Overfeeding is more of a concern with bottle-feeding; babies do tend to consume more when feeding from bottles and don't self-regulate as well. The mechanism of sucking from a bottle is completely different than that of suckling from the breast; babies can't really control very easily what they get from a bottle, but they can from the breast.

Breastfeeding babies can self-regulate. When they have enough, they'll stop nursing and go to sleep, or they continue to suckle a little but it's non-nutritive suckling. They're not really getting much breastmilk (or calories) at all at that point. But to an outsider who doesn't understand breastfeeding very well (as many pediatricians don't), this may look like "overfeeding," and they may pressure the mother to limit nursing.

To experienced parents, this sounds like nonsense---as it totally does to me now---but I remember worrying about this a little with my first. Newborns just seem to nurse and nurse and nurse without stopping sometimes....I remember feeling a little worred I might overfeed my baby and make her fat. I remember thinking maybe I should nurse a little less often, or to detach her and not let her fall asleep nursing.

Now, understand that I was a new mom, and there was no information about pregnancy and parenting for women of size then. My first pregnancy and birth had been very traumatic, and as a result, I was not at all confident in my parenting at that point. I really began doubting myself and my every decision.

And alas, cultural conditioning kicked in in a major way at that point. All my long involvement in fat acceptance organizations seemed to have been for naught, and most of my fat acceptance went out the window. I was consumed by fear that I might make my child fat. I knew she had the genetics for it and there was nothing I could do about that, but I was truly scared that I might somehow make it worse. So I began obsessing a bit about how much, how often, etc. I "should" nurse.

A combination of a very interventive birth, delayed/infrequent nursing at first, plus lots of bottles from the hospital led to breastfeeding problems. It took several months, but in the end, we were lucky.... breastfeeding worked out fine. And once she was finally nursing well, I was loathe to stop her. And I knew frequent nursing was important for building up my supply. So I started ignoring those cautions not to nurse "too long" or "too frequently." Once I did that, breastfeeding went much easier, her growth was fine, and I relaxed a little bit more about how often/how long/how much.

But in the beginning, the stuff I was reading made me worry about whether her long nursings were "overfeeding" her. So there were some times when I would stop nursing before she really wanted to stop, or make her wait just a little longer between feedings...simply because I was afraid of overfeeding her.

I wonder how many other fat mothers have done the same.

What Does a Good Pediatrician Look Like?

I was fortunate....I lucked into a great pediatrician. I was impressed by her calmness, her rational approach to things, her respectful approach in talking to me, and her willingness to take into account my own views and concerns. And so far, she has not pressured me about my children's weight at all.

My first child was a butterball in her first year. Cheeks from here to forever, lots of cute dimply folds, definitely not a tiny delicate child by any means. Yet the doctor never expressed any concerns. She could see that the baby was developing and moving well, walking at 9 obviously butterball status was not keeping her from being active. She was extremely supportive of breastfeeding, didn't want me to rush solids, and never lectured me about food.
She did measure my kids and chart their growth carefully, but she never mentioned trying to get them down further on the growth charts. She was mostly looking at the overall trend of their growth curve, tracking it to see that it remained relatively steady.

Over the years she has been supportive of all of my kids, whatever their size and shape. She knows that kids go through some bulking up just before they do a growth spurt; she never said a word as my two elder kids went up a little on the growth charts just before they hit puberty. My third child is hitting the pre-puberty butterball stage now, so we'll see how supportive she stays at his next appointment....but so far she has always been supportive and positive.

She does ask questions about an active lifestyle (which I'm fine with, because I understand the importance of exercise, whatever your size) but she doesn't harp on it a lot...because she knows my kids get plenty of activity through soccer, swimming, yoga, etc. She knows we limit TV and computer time reasonably and that we make sure the kids get outdoor time.

So far, she's been a truly awesome pediatrician because she seems to get that kids come in all sizes and shapes and it's their habits that matter more than their percentile on a chart. She asks questions and offers opinions but gets that the parent makes the ultimate decisions about the child's care, and that includes the child's feeding and activities, etc.

We'll see how she is as my kids get older, and we'll see if she remains supportive if any of them develop into significantly large kids instead of borderline kids....but so far, I have to say I've been as lucky as can be.

Finding a Size-Friendly Pediatrician

But I hear stories online, and not all of them are so supportive. Some of them are downright scary. And so much begins with the kind of feedback the parent of size gets from the pediatrician or family doctor.

That's why it's so important to find a pediatrician that is truly size-friendly. You can start by asking open-ended questions about their philosophies. Don't ask them leading questions; ask open-ended questions and then let them talk. You'll get a better sense of their views and protocols if they don't know what answer you are looking for.

For example, you might point out to them that obviously they are dealing with a parent who is larger than average. Ask them what their concerns are about that for the child and how that might influence their care of your child. Then let them talk and see what they say. A pediatrician who seems worried or obsessed about weight size will betray that; one who is accepting and calm will get that across too.

If you feel you need to, follow up with specific what-ifs....what if my child measures above the 85th percentile in their grade school years? What if they measure above the 95th percentile? What are their recommendations for frequency of nursing, for starting solids, for juice and milk intake etc. if the child is larger than average? Do they ever recommend dieting? These are the sorts of questions that will help you discern their underlying attitudes about weight and size.


I think most doctors that work with young children have developed a modicum of sensitivity about weight issues. Most won't harass or harangue the child or parent who is larger than average. There may be some hints here and there, but most aren't over-the-top about their concerns and show some sensitivity in how they approach things. There are even some who are truly "on board" with HAES as a philsophy and support it enthusiastically in their practice.

On the other hand, there certainly are horror stories out there about pediatricians and family doctors, and you simply can't assume respectful treatment anymore. With the obesity hysteridemic (and its particular focus on children), more and more pressure will be placed on these doctors to weigh, measure, "educate," and admonish.

So ask questions, write letters, interview potential doctors.....and never EVER settle for less than fantastic, size-friendly care......for either yourself or your children.

What have YOUR experiences been with pediatricians? Have they been mostly positive or negative or a little of both? What hints do you have for other parents-to-be in dealing with this issue?


Eema-le said...

Luckily I haven't had any problems with any of my daughter's doctors. Unfortunately she's had way too many doctors for her short 2 1/2 years. We moved recently, so I need to find yet another pedi, but I'm seriously considering sticking with her old one an hour away. There are a lot of inept and misinformed pediatricians out there. Especially when it comes to breastfeeding. We really have to be our own, and our children's best and loudest advocates. If something makes you uncomfortable, youhave to speak up.

Anonymous said...

My experiences have been very positive overall. My eldest was 95% percentile plus both for height and weight and I never got the slightest hint that he was too fat. The only thing recommended was that since he hit thirty pounds at nine months we had to get a new carseat, and that was totally a safety issue in case we had an accident.

All the advice I got about nursing was to do it whenever he wanted, and actually since he was a c-section and sleepy from the drugs we were told to never let him sleep more than four hours before waking him and trying to nurse!

I can't emphasize enough though that those early weighings are very important. My daughter's first symptom was that she lost an ounce (at three weeks, not the initial loss babies often have), which started a round of medical tests. She continued to lose weight and they found a minor heart defect which required surgery and saved her life. The doctors aren't just looking for fat in babies, but proper and expected growth. It was scary then, but she's a healthy bouncy girl of eight now.

I think pediatricians often see that kids have different body types. They look at those growth curves and say, yep this kid is always in this percentile for height and weight, must be normal for him. At least I often get a similar comment with all my three; and the two boys are definitely in the 85% plus range. I think this makes most of the more experienced ones aware that bodies vary, moreso than adult only docs anyway, who usually can't see the charts over such a period of time.

Anonymous said...

I'm not a mother but this brought back a lot of memories of my own pediatrician when I was a child. I was 50/50 on the growth charts (average height, average weight) my entire childhood and every year he warned me that I was about to get fat, and told me that I needed to exercise more because I was on the road to being fat. For some reason he had picked me out as a fat kid even though I never failed to weigh in at 50% every year. I remember one year I mentioned that I had tried horseback riding, and he warned my mom in front of me that he had seen kids get fat when they take up horseback riding.

Looking back, I can only guess that he was obsessed with childhood obesity and that's why he freaked out over my average weight and my lack of interest in athletics. But it always scared me, and I think that when I did start to worry about my body it was in large part because of him... my own doctor thought I was about to become a fat kid, which would obviously be a BAD thing.

So, even if your kids aren't fat, HAES doctors can be important -- it's good for kids to hear that the focus should be on their health, not on their weight.

Mindy said...

I had a ped who when we were in for an illness unrelated to weight berated me in front of my highly verbal two year old. When I took the conversation into the hall she told me: "it is always the mother's fault when the children are over weight" and asked if I wanted my daughter to become a statistic.
The doctor never asked about what she ate or what her activity level was when she wasn't sick.
I had to calm her down and agree to see a nutritionist in order to get the current medical problem looked at. We got the antibiotic prescription and she got better and I switched doctors and told the 1500 mothers on my parenting list the story and unrecommended the ped.

Varina said...

Wow, worrying about the weight of a baby is insane and almost malpractice. The last child I cared for was 95% for weight and 35% for height for a long time then suddenly at 12 months he shot up and became a tall, fairly skinny kid, which he still is. If his pediatrician or mom (also a pediatrician) had freaked about his weight he likely wouldn't have grown or developed as well. It's important for parents to realize that kids need fat and calories to grow and in fact kids can often eat much more caloricaly dense foods than adults since they have small stomachs but sometimes large calorie needs. With kids you should let them eat nutritious foods when they are hungry, make sure they are active, and not worry. This is especially true of babies who are growing and changing at exponential rates. Brain development is especially dependent on a large supply of glucose and cholesterol. Even with bottle feeding you should feed them whenever they are hungry, and there is definitely nothing wrong with comfort nursing.