Your Voice

Picky eating and the power of persuasion I have a suggestion after reading "Is the picky eater a cause for concern?" (March 2005). I find that, if we (as pediatricians) assume that an older child will not outgrow his pickiness, he will only fulfill our expectations. When I discuss nutrition with picky eaters who are 8 years or older, I reason with them, reviewing how they know fruits and vegetables are healthy and essential for good nutrition, and how they also know that eating such foods will not harm them. Once they agree with those two statements, I challenge them to try one new food a week. I have been very pleased with parents' reports and patients' self-reports about what new foods they are eating as a result of this technique. Children will surprise us if we challenge them with high expectations!

Deanna Yen, MDKnoxville, Tenn.

Author reply: It is encouraging that Dr. Yen has received positive results with her intervention. However, it also leads one to consider which component is responsible for that success. Studies have demonstrated that telling a child (9 to 11 years old) that a food is healthy for him reduces the child's perception of that food as palatable and his stated desire to eat that food in the future.¹ In addition, children's knowledge of fruits and vegetables (as contributors to health) does not correlate with how much they consume.² I suspect that the power of Dr. Yen's intervention comes from the positive reinforcement through verbal praise that the child receives from Dr. Yen (and from the parent) upon return to the office-as opposed to the reasoning or "cognitive" component of her intervention. Positive reinforcement in the form of praise from the pediatric provider can be a powerful modifier of behavior across a variety of domains in children.

REFERENCES 1. Wardle J, Huon G: An experimental investigation of the influence of health information on children's taste preferences. Health Education Research 2000;15(1):39

2. Gibson EL, Wardle J, Watts CJ: Fruit and vegetable consumption, nutritional knowledge and beliefs in mothers and children. Appetite 1998;31(2):205

Tongue-tie is an obstacle to breastfeeding Regarding "Tongue-tie in a newborn has minimal effect on breastfeeding success" (A POEM for your practice, May 2005): Based on my experience as a pediatrician and an internationally certified lactation consultant, I disagree with the findings of the referenced study that anklyoglossia only minimally reduces the likelihood of successful breastfeeding. Rather, in my practice, I have found anklyoglossia to be a significant cause of breast soreness, cracking, and bleeding. If I notice, either in the nursery or my office, that a breastfeeding newborn has ankyloglossia, I routinely perform a frenotomy with sterile scissors. This procedure takes a few seconds and causes minimal, if any, bleeding. Many mothers have reported immediate resolution of breastfeeding pain upon putting their newborn with the newly clipped tongue to the breast.

I would be interested to know the outcome of the study in terms of the presence of pain while breastfeeding, as well as the total duration of the breastfeeding relationship (not just one month) with the infants with anklyoglossia. I know of many mothers who "fight" through the pain in order to continue breastfeeding. Also, anklyoglossia will slowly result in a decreasing milk supply, as the tongue is unable to adequately milk the lactiferous sinuses and ducts that are under the areola. The mothers of these infants are the ones who report that they "didn't have enough milk" and forever think that they were never meant to breastfeed.

Deanna Yen, MDKnoxville, Tenn.

ClarificationThe June 2005 installment of "Rx for a Healthy Practice" did not provide a citation for a referenced study on office nurses' ability to provide immunization education to parents of your patients. The citation is: Davis TC, Frederickson DD, Arnold CL, et al: Childhood vaccine risk/benefit communication in private practice office settings: A national survey. Pediatrics 2001;107(2):E17.