LOGO : Site title

Hi, Dr. Friedman. Thanks for your time. Can you tell us a bit about yourself and your background?

I'm a general pediatrician and my full-time job is at Sick Kids Hospital in Toronto where I work in the pediatric medicine department. I'm originally from South Africa where I did my medical school training, but I did my pediatric specialty training here at Sick Kids. I've been here since 1990 as a resident and I guess I'm here 19 years later.

Oh, that's a long time looking after kids.

Yeah - it doesn't seem that long, looking back.

So that means that you were a pediatrician before you became a father, is that correct?

That's absolutely correct. I was already working as a pediatrician for about five years before my first child was born.

So, did you find that when you became a father your perspective on being a pediatrician changed?

I think that would be an understatement. I think I realized that what I'd been telling people for the five years before I became a parent I would have probably like to have taken some of it back because I think it totally opened my eyes to the whole world of parenthood and just how stressful and exhausting [it is], and how many questions there are, even as a pediatrician. My wife is an occupational therapist who works with kids so she's pretty comfortable with children and their development and even between the two of us I would have to say we realized how little we really knew about parenting. We might have had all the theory, but we certainly had a lot of questions. Which is really one of the things that motivated me to start writing these books, the realization that with all of the knowledge I still couldn't get the answers I was looking for.

Can you tell me some of the things that you wish you had taken back in the first five years?

When parents would ask about their babies and toddler who were not sleeping. Or they were concerned that they weren't eating enough or they were concerned that their developmental milestones were a little bit not quite exactly as they would have expected. 

I think prior to having my own kids I could sort of understand the question and I could sort give them a pat answer from a textbook, but I don't think I had any real understanding of how much it frightens a parent and how disruptive it is for a parent if, for example, when children are waking up three times a night or suddenly they don't seem to be eating as much as they should. I couldn't really appreciate how important those questions were. Having a pediatrician’s advantage it was much more about health issues, more about the medical part of it rather than the parenting part of it.

Would it be true to say that you became a better pediatrician after becoming a father?

Dr. Jeremy Friedman (photo courtesy of Meissner, de Groot & Associates)

I think I became a much better pediatrician.

So issues like sleep deprivation on your part and dealing with your kids in the middle of the night, did you experience those yourself?

Yeah, I think first of all having done medical school training and pediatric residency I was used to being woken up very often during the night.  But this is a completely different thing.  I found being on call during the evening and overnight as a pediatrician much easier than having to wake up and deal with my own child waking up in the night. 

When I think back it's all about being comfortable with what's expected of you. So as a pediatrician if I get called in for a child who's having an epileptic seizure or something I know exactly what to do and how to stop it. I know what the rules are and what I can and what I can't do. And I found that not particularly stressful. When my first child was in the first six months of life he literally woke up every 90 minutes. You become totally sleep deprived I just couldn't quite know how to deal with that and it was incredibly stressful.

Were you able to apply what you knew theoretically - the kinds of things that you've been telling the parents that you've been dealing with - were you able to apply that theory?

I think eventually we did. I mean for example, we in the book talk about sleep problems in frequent night wakenings - which is not an uncommon problem- we talk about the strategy of basically of what Ferber popularized where you do gradual extinction. To be honest I think that's not a solution for many families because it really depends on what sort of parent and what sort of philosophy you have and I think for many parents that can be a really difficult thing to do. They don't want to hear their baby cry and they're concerned about leaving them. 

For my wife and myself when our first one got to 6 months and we knew that at that point it was probably okay to try the strategy we just felt we had to do - that we didn't really have a choice.  We didn't want to hear him cry, but for us it worked. It was two or three nights of leaving him to cry it out a little bit and after that I must say he's been a fantastic sleeper.

That's such a relief when that occurs.

It obviously made an impression on me in terms of saying that this clearly can work in some children, but I must say as I've become more and more experienced I have realized that what I think about parenting is that it's not one size fits all. 

There really are many different ways to do things and I think one thing we've tried to do in the books is really not be too dictatorial. I think a lot of parenting books are written by people who really feel very passionate about a particular parenting style and they are very emotionally wound up in it. That's my experience with the parenting books that we bought when we had our kids. I kind of wanted to get away from that because I actually think that there are many different types of parents and what works for one set doesn't necessarily work for the others so I think you have to give people options and you can't tell them that this is the only way to do it. You can say "this will work" or "this will work with 3/4 of families, but it might not work for you."

That's a very challenging goal.  I agree with you that there are such a huge number of not only books but other resources as well and they really seem to come from the prescriptive position but I think the danger is, on the other side, if you want to be less prescriptive, there can be a tendency to be too wishy-washy.

I agree with you, but when we did this book I was adamant that a parent should be able to find the answer [they're looking for] in the book. Second of all, you would need to be able to literally read the part that you needed to in about 5 minutes without having to go through pages and pages of waffling and that there would be an emphasis on how-to strategies, literally taking you through. Not just giving you the philosophy of why you were doing it and the history of it and all that - but really take you through it from step 1 through to step 5 so that it really is a how-to book. So I'm hoping that we're not wishy-washy. We might give people options, but for each option we tell them exactly how to do it and try, I think, point out to them which things are likely to work quickly.

For example, co-sleeping. We'll point out what the dangers are, and when it really is risky in the first 6 months where you potentially can roll over and smother the baby and what the risks are. On the other hand, we mention that in the rest of the world co-sleeping is the norm. It's just in North America where really co-sleeping is the exception rather than the rule. So I think we just kind of try to put things in context .

What's the number one question you get from parents?

The number one question: "Is … normal?" It might be, "My child only eats chicken fingers and nothing else, is this normal?" Or, "My child is two years old and he only has two words, is this normal?" So I'm not sure there is one particular area that is overwhelming, there are certainly lots of questions about nutrition, lots of questions about sleep, lots of questions about development, but  a lot of them are really: "Is ... normal?" And that's why I think that we have definitely tried at each stage of toddlerhood to give a sort of spectrum of what is acceptable and also give a list of when the alarm bells should start ringing and when you should start perhaps getting an opinion from a healthcare person.

I guess behind that question on the various aspects of what may be considered normal is a certain level of fear and maybe paranoia.  Do you find that?  I don't know if it's appropriate to call it paranoia, I'm sure you see the different gradations of that.

Yeah, I think so. Certainly as a parent, I think we all get nervous when we see our kids’ playgroup or peer group doing things that our kids aren't doing, and worrying if they're behind. I don't know if a generation ago there was as much pressure for kids to always be at the above average kind of in everything.  Obviously by definition "average" means that half the kids will be a bit slower and half the kids will be a bit quicker. But it seems to me that this sort of pressure in North America is that everybody has to be above average, which is impossible.

I think there is a lot of anxiety when kids are a bit slower to meet their milestones. Yet when you look at them, down the line at school, at university, does it really make a difference if they spoke when they were one and a half, or two and a half? If they walked when they were one or one and a half?  There is no evidence to show that there is any difference at all.

Can you elaborate on the anxiety that you just referred to? The fact that you said that it seems to be particularly visible in the last generation, would you say that from the time that you started your practice you've seen a change in the anxiety level of parents?

I don't know if it's only since I started practice. My impression is, and I don't know how much it has to do with even the evolution of the media and the Internet and the availability of information, whether that has also fed into it a little bit. Because I think that people are much more informed than they have been before. And I think that it's partially true that this has happened over the last 20 years, people are much more informed, which I think is a very, very good thing, but sometimes the information is not necessarily in context and really can be misinterpreted.

Can you give me an example of how you've seen that misinterpretation or that sense of it being out of context?

I think there's a lot of information about attention deficit, ADHD, for example, and a lot written and a lot of talk. And people will read stuff about it and then they'll come to me and say, "I think my three- or four-year-old has ADHD."  And you know, part of the actual definition of ADHD is you have to be at almost school age, so you can't really diagnose ADHD at three or four because most of the features of the impulsivity and the lack of attention are developmentally normal in a three-year-old. But when you're six, if you're showing the same thing, you would have ADHD. As a three-year-old with the exact same symptoms, no, of course you don't because that's your developmental level at that point. You know information has been taken out of context when you don't have the whole picture and it can lead you down the wrong path.

I noticed in the book that you have charts that distinguish between the normal milestones and slower development, so I think that the fact that you situate it in that way seems pretty helpful. When I was reading it I was going through the charts and I wasn't always looking at the headings and reading the descriptions. And I thought, oh yeah, he passed this milestone a year ago!  And then I looked up at the headings and realized, that's for a different group.  So I think that it's great that it's there - I just have to be a more careful reader.

That's part of the thing. Particularly when one's reading stuff from different sources as well, one really has to be kind of savvy and look at the context where it's coming from. I really don't want to touch immunizations - that's another area. 

There's a lot of controversy about immunizations and it's very hard to definitively say that they're 100% safe. I don't think that anybody can say that, or should say that, because it's probably true of anything. Nothing's 100% safe. When I started my residency, I would see many kids with bacterial meningitis, which is often either fatal or causes permanent brain damage and then with the introduction of the immunizations that have happened, first of all the H-flu in the early 90's and more recently the pneumococcal. Now there's been a huge drop of it and we almost never see a case of bacterial meningitis. That makes a huge impact on me because I'm not seeing children being brain-damaged by this disease. I wasn't even around when kids were dying from measles and these other things.

There are various things people are trying to hook onto immunizations. You have to deal with them one at a time. The one that's getting the most press is the MMR and autism. There's been a tremendous amount of research trying to see if there is a link. The evidence is really against there being a link. I can't say that at some point there won't be some kind of connection between autism and some environmental issue. Clearly, it does seem to be getting more common. But I think people are probably pretty misinformed about this particular issue.

That's a very tricky path. First of all, research itself is not an easy thing to conduct with children, right?

It isn't. You almost have to study research methodology to be able to critique what the research is. I think a lot of it is actually not definitive and might actually be misleading. In fact the whole MMR/autism thing came from an article in a medical journal that started the whole thing off in the U.K. They retracted the journal article and all the authors retracted --  there was a lot of problems with what they did. I think in this case they've done 20 studies in 10 different countries and they've all found the same thing: that there wasn't an association. Looking back it's sort of likely that that's going to be true that there is no association, based on the volume and consistency from 10 different countries.

The other problem that arises when there is a retraction is that not everyone hears about the retraction. More people probably hear about the initial discovery.

One has to respect the media. I personally really like it when my patients come to me informed. They've read about whatever it is they're planning on asking me about. They have questions, but they're not starting from zero. Sometimes they'll even bring me a reference. I really like that. It adds to the richness of what you can do and talk about. The reality is the media  [decides that what] makes good press is something sensational. A sensational finding will often find its way into the headlines, but a retraction or the next study that shows it actually didn't occur is probably not going to make it in because that's not good news. It's definitely not going to make it into the mainstream news or television.

I find a lot of discussions I have with other parents have to do with correcting what we had previously assumed. I wonder if this is something you see in the parents you talk to. Around the time my son was born and for the first year, it was conventional wisdom that whenever he had a fever we would give him the appropriate dosage for his weight according to whatever symptoms he was demonstrating. A couple years ago, I remember hearing a doctor on the radio saying all of those should be poured down the drain. I felt a little betrayed.

I think you're absolutely right. As a parent it's a little disillusioning. That’s a good example, the cough and cold medications. Now they're not recommending cough and cold medications at all. For under 6 they're almost banned. I think it's quite an overwhelming statement. When you look at what it's based on: there is no evidence that it helps and there are a few cases of severe side effects.

If you look at the number of kids across North America, the incidence of side effects is incredibly rare. It's usually related to giving a little bit more than one should have. The reality is, if it's not really helping and there's a tiny risk of side effects then it's probably best not to be using them. When I was bringing up our kids, we didn't even have a thermometer because even a fever in itself is not the best marker of how your child is. The fever is like a burglar alarm. It tells you there's something going on, usually some kind of infection. But it doesn't usually tell you what's going on, whether you need to see a doctor because it doesn't really help.

The reality is you can tell when your child has a fever without using a thermometer. We talk about it in the medical chapter in the book. If your child has a temperature of 41 degrees, but he's eating and interacting and playing, then it's not that critical. It's probably some kind of viral illness, it'll run its course and then you'll be done with it. On the other hand if your child has no temperature but is refusing to eat, not interacting, seems drowsy, that child needs to be seen. Fever itself is not a great marker of what's going on.

Do you encounter new parents where making that mental transition is difficult?

It is. Doctors are very guilty of perpetuating that. When you go into a doctor's office, the first questions is, "What was your child's temperature?" I think that instills in parents' minds that that's an important factor. It is something that people cling to. Is it really that helpful? Not really, but it's something that people see as the right thing to do. 

What we need to teach the next generation of doctors, even before the parents, is to back off the medications and, even more important when it comes to the cough and cold medications, is actually to back off on antibiotics because the newspapers love the stories about the superbugs. Why are we seeing them? Because we're over-using antibiotics and the germs are getting too used to them. If you don't need an antibiotic then you shouldn't be taking it. If you do take it you have to take it properly, you have to finish the whole course. There's a lot of education, not just for parents. I think doctors are just as guilty of not keeping up with the advances in medicine and not helping the cause.

What do you usually tell parents to ease them of their concerns when, let’s say, in the case of a fever. You mentioned the mood of the child. When the parent brings in the child they're usually at a heightened state of anxiety.

What I tell them is that what causes the fever is the child's immune system fighting off the germs. That's what gives rise to the fever. I tell them I'm happy their child has a fever because it's telling me the child's immune system is kicking into gear and is fighting off what is most likely a viral infection. If your child had a viral infection and didn’t have a fever it would be potentially more worrisome. It would suggest their immune system is not kicking in as well as it should. So that often makes people feel more comfortable, that it's a sign the body is working more appropriately.

I always say to parents that if their child is uncomfortable with the fever, they can use something to bring down the fever. I know with my daughter she gets the sweats and hot and cold shivers and is really cranky and uncomfortable so I don't mind using something to make her more comfortable. In the context of a child that is really not feeling well and is getting some aches and pains, I'm quick to say they should give them a dose of acetaminophen (like Tylenol or Tempra) or ibuprofen, whichever you choose, they're pretty much the same. Give the appropriate dose, absolutely. But what I'm talking about is when children who have a fever aren't bothered by it. They just happen to have a fever, they're getting on with their business. There's no advantage to giving them anything.

Your advice would be to have it on hand but don't use it unless they're really uncomfortable.

Exactly. I usually say pick one. Every different formulation has a different dose. Just pick one that your child likes the taste of. That's the most important thing. They're all marketed slightly differently, but they all do the same job. Pick one your child likes the taste of and become really familiar with the dose, because chances are if you are going to use it, it's going to be at 3 in the morning when you're all groggy. You need to know exactly how much your child needs. Give them the dose, they'll probably feel better for the 4 or 6 hours until it wears off, but on the other hand if they feel a bit warm but are none the worse for wear, then fluids and TLC and see where things go.

We've talked a lot about the glut of parenting information. Given all that along with the fact that you see a lot of highly informed parents, do you see issues that tend to come up where you think the information is available, but it doesn't seem to make its mark?

I think that does happen. These days with the information on everything on the Internet. In Toronto you see such a multicultural mish-mash of people, there is a wide variation, particularly in the hospital setting. I see the whole spectrum. I don't just see one socio-economic section, it's right across the board. It is interesting how different parents are, certain cultures and ethnicities from various parts of the world. Some people don't want information. They want to be told what they need to do but are suspicious if you give too much information.

Then you have the people who want too much information, they want it written down, in triplicate. There really is a wide variation. There are some people that have the information, but they know what they believe and it doesn't really matter what you tell them, they're fairly fixed in their beliefs. I've found around things like immunizations, people come to me and say "I don't believe in them, I don’t believe that they're safe." I give them an opinion, but I realize in many cases they've thought about it a lot, they've come to their decision for whatever reason and we just have to accept that.

I hope the outcome is usually positive. Have there been any cases where it's been dire?

I would like to say that there are never issues. The truth is that we still see some cases, for example, of bacterial meningitis where the child has not been immunized. In those cases I don't go back to the parents and say, "Why didn't you immunize? Was it because it was against your beliefs or because you just didn't get around to it?"

They're already dealing with such a tragic, terrible illness. If they didn't do it they're probably carrying so much guilt that the last thing they need is someone to rub their noses in it. I must say I don't push that at all, but there definitely are cases where people don't immunize and their child does have a bad outcome. I think at the end of the day, you can't tell people what they have to do, you can only tell them what you see as the facts and then they have to do what they have to do.

So, what does your son Sam think about his diary being published in your book? Is he must be old enough to see it?

Yeah, he's just turned 10. He gets a kick out of seeing it and we ran it in the baby care book before the toddler care book. So his life has been documented from birth up until about 5. I think he gets a kick out of seeing it in print, he thinks he's a little celebrity, he enjoys it. My wife still keeps a diary even now. My two kids are 10 and 8. They're both almost like active contributors. If they do something really interesting at school or they get a note or letter from someone, they'll go to my wife and say, "Put this in your diary." It's almost become a bit of a journal to them. I hope one day they'll look back on it and show it to their own children.

It must help you both professionally and personally. It's like an album that might not have been put together if you hadn't been documenting it for the purpose of the books.

To be honest, the diaries existed before I started writing the book. We wanted something to flow through the book, just because there was so much information to make it a little less fact-intense. I thought, why not cut and paste from their diaries? The reality is what is in there is cut and pasted. I didn't really revise it. I literally took paragraphs out of our pretty extensive diaries.

What struck me was that you and your wife seem like the most patient parents ever.

My wife said that she wrote more when she was in a positive mood and maybe a little less when she was a little negative. Maybe there was a little emphasis on the positive. There definitely are parts where if you read between the lines we certainly had quite a bit of frustration with him, especially in the more sleep-deprived times. There was actually less diary to take from because there was less time to keep it up. I suspect we probably weren't as patient as might come across in those excerpts. On the other hand I wanted it to reflect reality. Hopefully we didn't gloss over the weird behaviours, anxieties and concerns we had with him, and probably still continue to have. Every child has their idiosyncrasies and weird behaviours and most parents will go through the same thing.

In this Internet age people are not only e-mailing, but with Facebook and Twitter, there's a lot more reflection of moments that might have been lost, not documented and then forgotten. I always find it interesting hearing people reflecting and dealing with issues like sleep deprivation as they're experiencing it. I think in the last few years it's given more texture to how parents cope.

I think you're absolutely right.

Through this web site, that's one of the things I want to reflect, the ups and downs and the different permutations of the parent experience. That's why I wanted to focus a little more on your experience as a parent as a pediatrician.

One of the things that did surprise me most was how difficult and stressful a job parenting is. I was also surprised on the positive side at how wonderful and high the highs were. The pleasure that almost gives you chest pain. The highs of the highs and the lows of the lows, both ends. It surprised me just how dramatic they were. In my normal life I don't think I'd ever experienced anything in that scope, the highs or the lows. What my wife always says is from reading the books she read and her understanding she didn't realize how difficult it could be. People often talk about how good things can be, but they often don't talk about how bad things can be. She was a bit shocked by that.

There's one reason I appreciate your book. I had been using What To Expect When You're Expecting: The Toddler Years which ends at 36 months. I used that as the "go to" guide. Then we got to the end and saw the milestones and realized that was the end. At that point things had plateaued in terms of the anxieties. I actually keep that book around to find out the temperature ranges and because that always seemed to be the lingering issue every winter when the fever would strike. But I felt I needed to have something that goes beyond 36 months because there's still stuff happening. That's probably true for the foreseeable future.

We used What to Expect in the first year when we had our kids, and it is a good book, but I haven’t looked at it in the last few years. My recollection was that it was a very thick book, a little dense and a little waffling that didn't personally help me. I wanted actual strategies and practical information. I'm sure it was all there and it was buried in there. I wanted our book to be different. I was looking for the baby and toddler "need to know. " The rest of the stuff - some people maybe want to read it - though not everyone has the time to read whole chapters. They could have cheered it up a little bit. I found it was boring and black and white. I wanted a more lively, alive book. And then also I wanted a little more research and scientific. Also because we're representing Sick Kids' Hospital and the Universiy of Toronto. I think our standard was making sure everything that was said could be backed to be a little higher than the standard of some of the other books that have been written by individuals.

Thanks again for your time.

You're welcome.