Concussions 101, a Primer for Kids and Parents (video)

Dr. Mike has put together a few resources on concussions at http://www.myfavouritemedicine.com/2012/03/07/concussions/

Dr. Mike Evans is founder of the Health Design Lab at the Li Ka Shing Knowledge Institute, an Associate Professor of Family Medicine and Public Health at the University of Toronto, and a staff physician at St. Michael's Hospital.

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Conceived, written, and presented by Dr. Mike Evans, Illustrated by Liisa Sorsa, Produced, directed, and filmed by Nick De Pencier, Picture and sound edit by David Schmidt, Gaffer, Martin Wojtunik, Whiteboard construction by James Vanderkleyn, Production assistant, Chris Niesing, ©2011 Michael Evans and Mercury Films Inc.

Vaccination: A Key Piece of the Puzzle (CDC videos)

Vaccination: A Key Piece of the Puzzle. Nothing protects babies better from more than 14 serious diseases by age 2.



Babies are on the move-- visiting grocery stores, playgrounds and other places with their parents and caregivers. As they come into contact with others, babies can be exposed to serious diseases, like measles and whooping cough:



The Immunization Baby Book: Flipping through this baby book, you can learn what vaccines babies need, when they're needed, and why it's so important to follow CDC's recommended immunization schedule.



For more information about vaccines, visit http://www.cdc.gov/vaccines/parents

A Best Friend Will Always Wait for You

Julian Burrett: "Watson the dog stands by while the boy does a quick assessment of the puddle situation. Could this be the cutest video ever? FAQs: Watson is a 12 year old Shar Pei." http://buff.ly/X2Jpr9

Health coalition asks Nickelodeon to stop marketing sugary and fatty snacks to children

A coalition of health groups thinks maybe it's time to enlist SpongeBob in the childhood obesity fight. Earlier this week, the groups asked the Nickelodeon Channel to stop airing commercials that promote unhealthy foods with the help of the doofy adorable sponge, among other lovable characters the children's channel employs. The letter the groups signed asked that Nickelodeon's parent company, Viacom, put in place strong nutrition standards for the foods marketed by it and by its characters. Their sentiment was strongly backed by the American Academy of Pediatrics.

Elise Viebeck of The Hill's Healthwatch blog quotes the letter: "Research shows that food marketing is an important factor contributing to children's poor diets and obesity. The majority of foods marketed to children remain of poor nutritional quality. The [federal Institute of Medicine] concluded that marketing puts children's health at risk." The letter went on to shake its finger at Nickelodeon for being behind Disney and other prominent child marketers on this front. (Read more)

This comes on the same day that the University of Missouri-Kansas City and the University of Kansas Medical Center release study results that found obese children may be more susceptible to food advertising than healthy-weight children, suggesting at least one reason the nation's childhood obesity rate could continue to climb as feared. (Read more)

No-Hit zones in place in pediatric wards of Kosair and U of L children's hospitals

Health professionals and other employees at Kosair Children's Hospital and the University of Louisville pediatrics unit were given an unusual tool this week when it was announced that their facilities are now No-Hit Zones. A program developed to maintain a calm, safe and caring environment for children and their parents, the No-Hit Zone initiative works to educate staffers on how to keep everyone on the ward safe from those who would lose their tempers while everyone around them is already in a stressful situation.

The policy is quite clear. No adult shall hit another adult. No adult shall hit a child. No child can hit an adult. And no child can hit another child while in the hospital environment.

The Kosair Children's, Kosair Children's-Brownsboro and U of L hospitals are now among only 30 children’s hospitals nationwide to implement the No-Hit Zone program. The Louisville effort has been led by Erin Frazier, M.D., FAAP, associate professor of pediatrics at the Uof L Children & Youth Project, and the Kosair Children’s Hospital Child Abuse Task Force, which Dr. Frazier chairs.

To learn about the No-Hit Zone, go here.

Study finds kids get more fat and calories when they eat out

Nobody's surprised to hear what researchers have now quantified: When children eat out, they take in more calories and fat than they would have at home. It doesn't matter if they're sitting down or driving through, at a fancy restaurant or at a McDonald's, we're not doing them any nutritional favors when we get in the car to go eat.

Jon Bardin of the Los Angeles Times reports that a study, published Monday in the medical journal Archives of Pediatrics & Adolescent Medicine, found that 2- to 11-year olds average an extra 126 calories when they eat a fast-food meal and 12- to 19-year-olds add an average of 309 calories. Full-service restaurants could added an average of 160 and 267 for the two age groups, respectively. And a lot of those calories were of the empty-nutrition kind that come from sugary drinks; kids in the study drank significantly more of those while dining out than when eating at home. (Getty Images photo)

In their report, writes Bardin, the authors argue that government intervention likely will be required to see any improvement: “Public policies that aim to reduce restaurant consumption -- such as increasing the relative costs of these purchases; limiting access through zoning, particularly around schools; limiting portion sizes; and limiting exposure to marketing -- deserve serious consideration.” (Read more)

Use of pacifiers could lead to very sick babies, study finds

Oklahoma State University researchers report that they have found a wide range of disease-causing bacteria, fungus and mold on pacifiers that young children had been using.

In research presented at the American Society for Clinical Pathology, scientists have shown that pacifiers can also grow a slimy coating of bacterial film that alters the normal bacteria in a baby or toddler's mouth, increasing the likelihood of colic and ear infections. It gets worse, according to study author Tom Glass, a professor of forensic science, pathology and dental medicine: The same types of bacteria found on a common pacifier have been linked to cardiovascular disease, metabolic syndrome, allergies, asthma and autoimmune diseases.

HealthDay reporters Barbara Bronson Gray writes that Glass said the problems associated with pacificers are also applicable to any removable orthodontic appliance like retainers, mouth guards and dentures. Glass said his researchers were particular concerned about their findings when they discovered that "many of the bacteria growing from the used pacifiers were resistant to commonly used antibiotics such as penicillin and methicillin. The development of such resistance to certain antibiotics does not cause the organism to be more infectious than other strains that have no antibiotic resistance, but it can make the infection more difficult to treat." Glass told Gray that he does not recommend that pacifier use. use. "After doing the study, I say why take a risk?" (Read more)

State's hospitals see impressive growth spurt from nearly $1 billion in capital investment

Kentucky’s major hospital systems are going big, making high-profile, technology-forward capital investments across the commonwealth. Josh Shepherd of The Lane Report writes that every sector of the state is part of the hospital boom. The state's cumulative total of investment since 2010 is roughly a billion dollars, notes Shepherd, and has meant hundreds of construction and, soon, medical and other hospital-related jobs. Here's the list of the most notable construction projects now under way:

Owensboro Medical Health System,  $385 million, a new complex (pictured, above) that will allow expansion for the next 50 years, completion date: summer 2013.

Norton Healthcare System, Louisville, converting Suburban Hospital into Norton Women's Hospital and Kosair Children's Hospital, $120 million, completion date: 2013.

Pikeville Medical Center, new office building and parking facility, $130 million, completion soon.

Baptist Health, Lexington, expansion of Central Baptist Hospital medical services complex with parking structure, $200 million.

University of Kentucky Healthcare, Chandler Medical Center, $750 million, includes new plans for Shriners Hospital for Children.

Frankfort Regional Hospital,  $8 million expansion, emergency department.

Trigg County Hospital, $7 million, surgery and rehabilitation unit.

Lifepoint Hospitals-owned Clark Regional Medical Center, $60 million, 79-bed hospital. (Read more)

Anthem PPO plan chosen as 'benchmark' for state's Kentucky Health Benefit Exchange

The Kentucky Department of Insurance has recommended that the Anthem Preferred Provider Organization (PPO) plan serve as the “benchmark” plan for the Kentucky Health Benefit Exchange, as well as for plans offered outside the exchange. The statement issued by the department states that "Anthem PPO is the largest small group plan currently offered in Kentucky and includes coverage for all state mandates and the 10 essential health benefits, or categories of care, specified by the federal government under the Patient Protection and Affordable Care Act. The benchmark plan sets the minimum level of benefits offered in the individual and small group markets beginning Jan. 1, 2014."

According to the release, the Anthem PPO plan "is the most cost-effective of the 10 plans reviewed, will not create additional costs for the state and should not increase the price for those who have coverage today. Since the Anthem PPO plan does not offer the minimum requirements for pediatric vision and dental services, Kentucky has recommended that the benefits in the Kentucky Children’s Health Insurance Program (KCHIP) be substituted in the benchmark plan."

Some background, also provided by the Dept. of Insurance: One of the goals of the Affordable Care Act is to ensure that Americans will have access to quality, affordable health insurance. To achieve this goal, the law ensures health plans offered in the individual and small group markets offer a comprehensive package of items and services, known as Essential Health Benefits. The act provides that the EHBs include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. For more on Essential Health Benefits, go here.

The U.S. Department of Health and Human Services will review the Athem recommendation and accept public comments prior to making a final decision on the matter.

UK medical center is fifth in the nation to be recognized for out-of-body respirator help for babies, children and adults

Because they use extracorporeal (out-of-body) membrane oxygenation, or ECMO, to support patients, the University of Kentucky's Albert B. Chandler Hospital and Kentucky Children's Hospital have been awarded a triple designation from the Extracorporeal Life Support Organization. UK is just the fifth medical center to receive the triple-designation honor, reports UK's Allison Perry. (UK photo)

ECMO uses an artificial lung device that gives "cardiac and respiratory support to patients whose heart and lungs are so severely damaged that they can no longer function," Perry reports. "It can also serve as a bridge to transplantation, allowing patients to not only survive, but to become stronger and healthy enough to undergo the transplant surgery." The technique is used on neonatal, pediatric and adult patients, hence the triple designation.

"This designation is another example of the expertise and advanced technology available for neonatal to adult patients who require complex care that can only be provided at top academic medical institutions," said Dr. Michael Karpf, UK's vice president for health affairs. (Read more)

Unipolar depression in adolescence is common worldwide but often unrecognized

Unipolar depressive disorder in adolescence is common worldwide but often unrecognised. The incidence, notably in girls, rises sharply after puberty and, by the end of adolescence, the 1 year prevalence rate exceeds 4%.

The burden of depression is highest in low-income and middle-income countries. Depression is associated with morbidity, and heightens suicide risk.

The strongest risk factors for depression in adolescents are:

- family history of depression
- exposure to psychosocial stress

Factors that interact to increase risk through hormonal and perturbed neural pathways include:

- inherited risks
- developmental factors
- sex hormones
- psychosocial adversity

References:

Depression in adolescence. Prof Anita Thapar et al. The Lancet, Volume 379, Issue 9820, Pages 1056 - 1067, 17 March 2012.

Image source: OpenClipArt.org

More than 50% of injuries on Fourth of July are related to fireworks

The eyes are the most frequently injured body parts, followed by the fingers and hands. Here is a video from the Cleveland Clinic with some advice how to prevent these injuries:



This video discusses ways to prevent and identify heat-related illness in senior citizens:

Drowning Prevention Guidelines

Here is a video from the Cleveland Clinic:



Key risk factors for drowning are:

- male sex
- age of less than 14 years
- alcohol use
- low income
- poor education
- rural residency
- aquatic exposure
- risky behavior
- lack of supervision

For people with epilepsy, the risk of drowning is 15 to 19 times as high as the risk for those who do not have epilepsy.

For every person who dies from drowning, another four persons receive care in the emergency department for nonfatal drowning.

Drowning Doesn’t Look Like Drowning

- Except in rare circumstances, drowning people are physiologically unable to call out for help. The respiratory system was designed for breathing. Speech is the secondary or overlaid function. Breathing must be fulfilled, before speech occurs.

- Drowning people’s mouths alternately sink below and reappear above the surface of the water.

- The mouths of drowning people are not above the surface of the water long enough for them to exhale, inhale, and call out for help. When the drowning people’s mouths are above the surface, they exhale and inhale quickly as their mouths start to sink below the surface of the water.

- Drowning people cannot wave for help. Nature instinctively forces them to extend their arms laterally and press down on the water’s surface. Pressing down on the surface of the water, permits drowning people to leverage their bodies so they can lift their mouths out of the water to breathe.

- Throughout the Instinctive Drowning Response, drowning people cannot voluntarily control their arm movements. Physiologically, drowning people who are struggling on the surface of the water cannot stop drowning and perform voluntary movements such as waving for help, moving toward a rescuer, or reaching out for a piece of rescue equipment.

- From beginning to end of the Instinctive Drowning Response people’s bodies remain upright in the water, with no evidence of a supporting kick. Unless rescued by a trained lifeguard, these drowning people can only struggle on the surface of the water from 20 to 60 seconds before submersion occurs.

References:

Drowning Doesn’t Look Like Drowning. Mario Vittone.On Scene Magazine: Fall 2006 (page 14)
Drowning - free NEJM review, 2012 http://goo.gl/xSqLu

Hemophilia educational videos by CDC

Hemophilia belongs to a family of inherited lifelong bleeding conditions that prevent blood from clotting properly. Patients with these disorders bleed for longer than normal, either as a result of injury or spontaneously without an external cause.

The severity of bleeding depends on the amount of clotting factor that is missing or not functioning properly, which in hemophilia A and B - the most common types of hemophilia - is the coagulation factors VIII and IX, respectively.

In addition to external bleeding, patients more commonly have internal bleeding around the joints and muscles, which can be extremely painful and cause permanent disability. Bleeding into major organs such as the brain is especially difficult to manage and can be fatal.

Here are 2 hemophilia educational videos by CDC:  Playing it Safe With Hemophilia: Friends with hemophilia talk about playing sports growing up and the importance of making smart decisions.



Starting the Conversation: Hemophilia. How to talk to your friends about hemophilia. A group of friends ask their friend Billy questions about his hemophilia:



Hemophilia care has undergone substantial improvements during the past 40 - 50 years. Early clotting factor concentrates were not sufficiently refined to enable self-administered treatment at home until the 1970s.

Long-term substitution therapy (prophylaxis) of the missing clotting factor is the recommended treatment in severe hemophilia. The major side-effect of treatment, development of inhibitors to the infused concentrate, is the main threat to the health of patients.

Mnemonic: Differential Diagnosis of Bleeding Disorders: F-CAP

Fibrinolysis - tPA
Coagulopathy - hemophilia, vWD
Angiopathy - conditions affecting blood vessels, e.g. Osler-Weber-Rendu syndrome
Platelets - thrombocytopenia or thrombocytopathia

Initial diagnostic tests = 3P:

Platelets
PT - INR
PTT

References:

http://www.cdc.gov/NCBDDD/video/Hemophilia_sports/index.html

http://www.cdc.gov/NCBDDD/video/Hemophilia_Friends/index.html

Making haemophilia a global priority - The Lancet, 2012.

Modern haemophilia care - The Lancet, 2012.

The Diet Factor in Attention-Deficit/Hyperactivity Disorder - State-of-the-Art Review Article in Pediatrics

Diets that were tried in attempt to reduce symptoms associated with attention-deficit/hyperactivity disorder (ADHD) include:

- sugar-restricted
- additive/preservative-free
- oligoantigenic/elimination
- fatty acid supplements

Omega−3 supplement is the latest dietary treatment with positive reports of efficacy. Interest in the additive-free diet of the 1970s is occasionally revived.

Provocative reports have drawn attention to the ADHD-associated “Western-style” diet, high in fat and refined sugars, and the ADHD-free “healthy” diet, containing fiber, folate, and omega-3 fatty acids.

Indications for dietary therapy include:

- medication failure
- parental or patient preference
- iron deficiency
- change from an ADHD-linked Western diet to an ADHD-free healthy diet, when appropriate

In practice, additive-free and oligoantigenic/elimination diets are time-consuming and disruptive to the household; they are indicated only in selected patients.

Iron and zinc are supplemented in patients with known deficiencies; they may also enhance the effectiveness of stimulant therapy.

In patients failing to respond or with parents opposed to medication, omega-3 supplements may warrant a trial.

References:

The Diet Factor in Attention-Deficit/Hyperactivity Disorder. J. Gordon Millichap, MD and Michelle M. Yee, CPNP. PEDIATRICS Vol. 129 No. 2 February 1, 2012, pp. 330 -337, (doi: 10.1542/peds.2011-2199)

Image source: Olive oil, Wikipedia

Children’s ability to "roam" has been destroyed, and they congregate on social media sites

From the the NYTimes:

Danah Boyd, a senior researcher at Microsoft and an assistant professor at New York University: “Children’s ability to roam has basically been destroyed. Letting your child out to bike around the neighborhood is seen as terrifying now, even though by all measures, life is safer for kids today.”

Children naturally congregate on social media sites for the relatively unsupervised conversations, flirtations, immature humor and social exchanges that are the normal stuff of teenage hanging-out, she said.

Moreover, grown-ups’ panic about teenage online behavior distracts from the potential benefits.

Let kids be kids - unstructured play time may be more important than homework, suggests a childhood psychologist. "Children have lost 8 hours per week of free, unstructured, and spontaneous play over the last 2 decades due to homework. Decrease in unstructured play time is in part responsible for slowing kids’ cognitive and emotional development. Today’s 5-year-olds had the self-regulation capability of a 3-year-old in the 1940s; the critical factor seems to have been not discipline, but play."

Video: A life cycle in 90 seconds:



References:

Cracking Teenagers’ Online Codes. NYTimes, 2012.

Image source: OpenClipArt.org, public domain.

Antibiotics prescribed during 21% of pediatric ambulatory visits; 50% were broad-spectrum

Antibiotics are commonly prescribed for children with conditions for which they provide no benefit, including viral respiratory infections.

The researchers used the National Ambulatory and National Hospital Ambulatory Medical Care surveys from 2006 to 2008, which are representative of ambulatory care visits in the United States.

Antibiotics were prescribed during 21% of pediatric ambulatory visits; 50% were broad-spectrum, most commonly macrolides. Respiratory conditions accounted for >70% of visits in which antibiotics were prescribed.

The authors concluded that broad-spectrum antibiotic prescribing in ambulatory pediatrics is extremely common and frequently inappropriate.

Cough is one of the common reasons for unnecessary antibiotic prescription. As you can see from the diagram below, the differential diagnosis of chronic cough is broad and includes asthma and other conditions in which antibiotics are ineffective:



Differential diagnosis of cough, a simple mnemonic is GREAT BAD CAT TOM. Click here to enlarge the image: (GERD (reflux), Laryngopharyngeal Reflux (LPR), Rhinitis (both allergic and non-allergic) with post-nasal drip (upper airway cough syndrome), Embolism, e.g. PE in adults, Asthma, TB (tuberculosis), Bronchitis, pneumonia, pertussis, Aspiration, e.g foreign body in children, Drugs, e.g. ACE inhibitor, CF in children, Cardiogenic, e.g. mitral stenosis in adults, Achalasia in adults, Thyroid enlargement, e.g. goiter, "Thoughts" (psychogenic), Other causes, Malignancy, e.g. lung cancer in adults).

References:

Antibiotic Prescribing in Ambulatory Pediatrics in the United States. Adam L. Hersh, MD, PhDa, Daniel J. Shapiro, BAb, Andrew T. Pavia, MDa, Samir S. Shah, MD, MSCE. Pediatrics Vol. 128 No. 6 December 1, 2011, pp. 1053 -1061, (doi: 10.1542/peds.2011-1337).

Image source: Wikipedia, GNU Free Documentation License.

"The online version is the official journal of record, not the print edition". Start a blog in 2012

"The online version is the official journal of record", wrote the Editor-in-Chief and the editorial staff of Pediatrics, the official journal of the the American Academy of Pediatrics:

"As we start 2012, and welcome the more than 6 million annual visitors to our journal's Web site, we remind our readers that the online version, not the shorter print edition, is the official journal of record. Is it time to do away with the print version? Probably not just yet, but it may not be long until we are heading in that direction.

If you are thinking, “there are so many options to peruse and so little time!” you will find some highlights of each issue in our blog - First Read - which contains previews of articles of interest selected by members of our executive editorial board. We are even running some of our most interesting “fillers” from the print journal in the blog so they are not missed by our online readers"

This is the URL of the blog which is hosted for free on Blogger.com by Google: http://pediatricsblog.blogspot.com

All physicians should consider starting a blog in 2012

I would encourage all physicians to start a blog in 2012 - here is why (quotes from an interview with Seth Godin and Tom Peters):

"Blogging is free. It doesn’t matter if anyone reads it. What matters is the humility that comes from writing it. What matters is the metacognition of thinking about what you’re going to say.

No single thing in the last 15 years professionally has been more important to my life than blogging. It has changed my life, it has changed my perspective, it has changed my intellectual outlook, it’s changed my emotional outlook. And it’s free."



Don't limit yourself to your blog - use Facebook, Twitter and Google Plus

Blogging can be great for personal growth but there is a lot more interaction on Twitter, Facebook and Google Plus nowadays as compared to blogs. If you have a blog, you must also have a Facebook "like" page (previously called "fan" page), a Twitter account, and probably a Google Plus page. These serve the dual purpose of distribution and commenting channels ("two-way street").

For example, Facebook pages get a lot more interaction than blogs for some medical journals - you can compare the number of comments on the NEJM Facebook updates (the range is 9-180) vs. their blog (0). The blog has comments enabled, of course.

Facebook is the clear "winner" in terms of commenting activity, it is not even close:

NEJM Facebook page vs. NEJM blog

This is a suggested simple project for all doctors in 2012:

1. Start on Twitter (microblog).
2. Continue on Blogger/WordPress.
3. Make an impact. Improve the quality of online health information and tell the public your side of the story.

How to Create a Blog on Blogger in 5 minutes (Google video):



Help your patients and your practice

I developed the concept of Two Interlocking Cycles:

- Cycle of Patient Education
- Cycle of Online Information and Physician Education

The two cycles work together as two interlocking cogwheels (TIC):



References:

Taking the Pulse of Pediatrics. PEDIATRICS Vol. 129 No. 1 January 1, 2012, pp. 168 -169 (doi: 10.1542/peds.2011-3288).

Social media in medicine: How to be a Twitter superstar and help your patients and your practice

Patients directed to online tools don't necessarily use them: 25% checked website vs. 42% read same material on paper. Am Medical News, 2012.

Stuttering affects 1% of schoolchildren - early intervention is recommended, within 1 year of onset

Stuttering, also known as stammering, is a common speech disorder of neural speech processing that typically begins during the first 3-4 years of life. A review of 44 studies shows a prevalence of around 1% for schoolchildren.

Stuttering is a movement disorder of speech, with effects on the:

- jaw

- mouth

- facial muscles

- sometimes upper limbs

People who stutter are at risk of developing social anxiety or mental health problems. Educational, occupational, and social problems are common if chronic stuttering is not treated early

It is not possible to predict who will recover spontaneously. The window of opportunity is to treat children within one year of onset.

Early intervention is recommended, preferably within one year of onset of stuttering. Speech restructuring can rehabilitate speech in people with chronic stuttering

References:

Clinical management of stuttering in children and adults. BMJ 2011; 342:d3742 doi: 10.1136/bmj.d3742 (Published 24 June 2011).

Social relations as a primary factor for children’s happiness

The relation between the global happiness and school-related happiness of 700 12-year-old Finnish students was examined.

The results showed a strong relationship between happiness and social relationships.

The most popular choices of the happiness increasing factors were:

- success in school
- more free time
- success in a hobby

The least happy students more often than others wanted to have:

- more friends
- better looks
- more money
- a peaceful family life

The results confirm safe social relations as a primary factor underlying children’s happiness.

References:

Global and School-Related Happiness in Finnish Children. JOURNAL OF HAPPINESS STUDIES, 2011.

Comments from Google Plus:

Howard Luks - Our children's lives are far too structured and planned. We have a neighborhood full of young children, yet we are the only ones outside playing. Others are being shuttled to this and that, etc... sad. Let them learn, let them explore, let them socialize and start to cultivate the skills that will last them a lifetime... all IMHO +Wendy Sue Swanson thoughts?

Ves Dimov - Let kids be kids: unstructured play time may be more important than homework

http://casesblog.blogspot.com/2010/03/let-kids-be-kids-unstructured-play-time.html

Howard Luks - Couldn't agree more. Love how you find your links so fast :-)

Ves Dimov - My blog is my searchable archive... And the word "unstructured" rang a bell... :)

Wendy Sue Swanson - I like this thinking. I like the freedom to imagine that children will have space to remain present in their moments, that they'll consider the future without boundaries like they can when roaming in the yard. The structured and planned is becoming a norm---but there is resistance and more and more, parents are thinking about leaving their kids to the space and time they were afforded. With all of the parenting advice that is ever-present, it's hard for some parents to turn it off and tune back into their instincts. When you hear about the necessities of children learning 3 languages before age 7 (because the brain is primed until that age, thereafter it's far more difficult) it's hard not to jump in the car to the language school. This is the curse of more and more research--we get misdirected. We feel we can "perfect parenting." We forget we need time to stare up at the sky...time in the backyard with our hands in the sand and our brother at our side. We need to be able to remember that when life is still and we reflect on what matters, it's unlikely to be the language lesson.