Why Does Recent Pediatric Guidance Feel So Judgmental?

In the overheated world of parenting advice, the pediatrician is a moderating voice. If your relatives say sleep training is cruel or a TikToker claims day care causes behavioral issues, you can usually count on your pediatrician to assure you, Your kid is fine and you can tell your mother-in-law I said so.

But two recent recommendations from the American Academy of Pediatrics (AAP), the country’s largest association of doctors who treat children, seemed to place pediatricians at odds with many parents in the ongoing battles over parenting choices. Even people who don’t normally pay attention to the recommendations of professional medical organizations took note.

First, in 2022, the AAP announced that it now recommended breastfeeding until the age of 2 or longer, a doubling of the old recommendation of at least 12 months. Breastfeeding for any period of time is a struggle in a country with no paid parental leave, and this recommendation happened to arrive in the throes of the formula shortage. As if we didn’t already feel bad enough for giving up breastfeeding!

Then, at the beginning of this year, the AAP published new childhood obesity guidelines that called for treating obesity as a serious health condition that in some cases required immediate intervention. Instead of the staged, “watchful waiting” approach that had previously been the standard, the new guidelines called for intensive behavior and lifestyle modification for 6-year-olds (and even younger where appropriate), medications for kids as young as 12, and referral for bariatric surgery children with severe obesity as young as 13.

These guidelines were more complicated, and more controversial. Advocates had spent decades working to fight anti-fat bias and separate weight from health — a movement that trickled down into parenting advice that focused on health at any size and loving one’s body. The new guidelines seemed to scream, Sorry, actually fatness really is intolerable.

It’s safe to say that most pediatricians don’t aspire to be a source of parental anxiety. (If they wanted to do that, they could skip medical school and go straight to being parenting influencers.) But it is nonetheless dreadful to go into a doctor’s office anticipating judgment of your parenting choices or, more upsettingly, your child’s body.

In August, Romper spoke to Dr. Sandra Hassink, M.D., FAAP, and Dr. Maya Bunik, M.D., two pediatricians involved in writing the AAP’s obesity and breastfeeding guidelines, respectively. They explained why and how the AAP decides to update its guidance, how they think about the backlash to some of their recommendations, and how pediatricians are working to repair trust in the medical field.

Romper: How is the pediatrician-parent relationship unique in medicine?

Dr. Hassink: It’s very unlike adult medicine. We’re interacting all the time with family, not only nuclear families but also grandparents and all caretakers. So it’s child- and family-centered, which I think does differentiate it from adult medicine. We’re adult educators in that sense.

Dr. Bunik: It’s also unique in that we help people through what is probably one of the biggest life changes, having a baby, and we are in a position to reassure, empower, and help problem-solve… There’s so much information now on the internet that it is really important to have trust in someone, where you can even talk through some of the things that you’ve read about or that you’ve heard about from others. Find someone that has similar ideas to you and that you really feel is a partner you can trust.

Romper: Does the Googling mom and dad, and all the information that they have access to, change your role as physicians and experts? Does answering questions from the internet take up a bigger part of your clinical practice?

Hassink: I always welcome when parents bring in what they’re looking at and seeing. It can tee off a discussion and help me understand what their concerns are. We can walk together through what it means compared to what the Academy might be saying or what their grandparents are saying.

This reciprocal relationship is so important that, in the clinical practice guidelines for obesity, the AAP highlighted that longitudinal partnership with parents and families, that need for pediatricians to develop and use skills like motivational interviewing, so that we’re sure we can understand where the parents are coming from. What’s on your mind? What are you worried about? What are your concerns? We’ve actually built that into our clinical guidance.

Bunik: In breastfeeding, certainly, I spend probably half of the first visit just going over all the things that they’ve read on the internet. The first five pages of Google are just adamant people with opinions, not necessarily stuff that will really work, right?

Romper: The average person might have more opinions about breastfeeding and obesity (and the AAP statements on the topics) because, although they are health issues, they’re also related to relationships and culture. Non-medical factors play into families’ decision-making. Are parents the intended audience for AAP recommendations? And how do you decide it’s time to make a set of recommendations on a given topic?

Bunik: It is AAP policy that existing policy statements be reviewed and evidence updated. For breastfeeding, certainly, the research evidence had to be reviewed. We couldn’t ignore it. Our action is to review: What are best practices, and what is the evidence for it? The policy statement goes through all kinds of expert review and peer reviews. It really is supposed to be a North Star of where we should be headed. The public and professionals need to know that extended breastfeeding extends benefits for both mom’s health and baby’s health. The longer you do it, the relative risk of various diseases decreases.

Hassink: Obesity and obesity complication rates in children have continued to rise. There has also been a significant increase in obesity treatment research. A mechanism for a rigorous, evidence-based approach to evaluating this research also became available through our Council on Guideline Development. These factors, along with the fact that it had been 15 years since the AAP had issued any formal guidance on obesity treatment, were the impetus for the clinical practice guidelines.

There are several levels of documents that the Academy produces: clinical reports, technical reports, policy statements, and clinical practice guidelines. The obesity report was a clinical practice guideline, which has the highest, most rigorous burden of evidence. It’s a very long, involved procedure. The guideline is aimed primarily at the pediatrician, to say this is the evidence base upon which you can rely in treatment. That said, it is difficult to discuss children’s health, or obesity for that matter, without acknowledging the systematic and structural barriers and associated policies that could support better treatment, so there is a small section of the CPG that identified these areas for change.

And that’s not to say that stakeholders, policymakers and educators, and parents can’t read it. But recommendations that say should reflect the level of evidence that made that recommendation happen. There is no should, as in everybody must do something. It’s the high level of evidence. The guidelines take the evidence in discussion with the family, the understanding of the child’s situation, the understanding of the whole context, and then they make a decision about how to move forward.

I happened to say to this one mom, who had three sons all struggling with obesity, I said, “You know, I’ll never judge you.” And she burst into tears and she said, “I feel judged everywhere I go.”

Romper: Anxious parents forget the context in their own decision-making and think, Well, I have to do this and now, you know, or by the AAP standards, I’m a bad mom or person.

Hassink: I’m sorry that that is a confusing point, but I think the whole point is a pediatrician must have the best evidence. That’s step one. Step two is the whole rest of it. Understanding the context, understanding the family, dialoguing with the parents. The evidence is step one, but without the evidence you can’t bring the best treatment to the family.

Some of this emotion around obesity is from the cultural weight bias stigma, which is pervasive and toxic. We wanted to get out there the idea that obesity is a disease. It’s medical. It has treatment. People should not feel blamed because they have obesity.

Obesity is a complex chronic disease. It should be followed longitudinally. People should be able to get treatment. Lifestyle and behavioral treatment, then pharmacologic treatment and surgery if needed. There’s equity issues there too because there are people who cannot get treatment. So this was evidence-based, but it was also an attempt to stand up against weight bias and stigma, against the fact that people were being blamed and blaming themselves.

I have seen people crying in my office they felt so badly. I happened to say to this one mom, who had three sons all struggling with obesity, I said, “You know, I’ll never judge you.” And she burst into tears and she said, “I feel judged everywhere I go.” Moms with toddlers who have obesity — strangers come up to them in the grocery store. But the evidence around obesity is that it is a disease and that’s part of what we were doing as well as contextualizing this for people. So ironically maybe, we were trying to remove blame and guilt, and I think your point was that a lot of that got lost. People took it as I should, should, should. Meanwhile, in the beginning of the guideline, we’re saying it’s a chronic disease and there’s no blame here. There’s treatment. There’s a lot of unwinding here that parents need help with.

Romper: How do you weigh the need to communicate evidence that is difficult to hear for some people versus the need to maintain a trusting relationship with families who are getting unscientific or politicized information elsewhere?

Hassink: Take the case of a child who is over 12 who has obesity. They should be treated and the evidence with obesity is that medication is effective (the AAP’s criteria for medication is a BMI in the 95th percentile or higher), and surgery for children over 13 who have severe obesity (BMI greater than or equal to 120% of the 95th percentile) is effective. To not tell a family who is struggling that these treatments are effective because it’s controversial or because I know that society’s talking a lot about this, would also not be correct.

Same goes for breastfeeding. The fact that parental leave is not a policy of this country is tragic, right? It is not the fault of any parent anywhere. But not to say that breastfeeding is important is not serving us well because sometimes this kind of evidence is used to push policy.

Romper: Many people do use scientific evidence as a parenting North Star. The challenge is that parents in this country feel that they have to personally make up for the shortcomings of society.

Hassink: Parents have to interpret what part of this recommendation they are going to internalize as their responsibility, and what part they are going to say, “Maybe I’ll go lobby a lawmaker, but I don’t have to take total responsibility and feel guilt if my company doesn’t provide that.” That’s where your pediatrician can help you. I’m not going to tell you to do something you absolutely can’t do or is not right in your circumstances. We’re going to have a dialogue.

Bunik: The medical profession and training doesn’t really support breastfeeding very well, so there’s a lot of internal issues that we have to deal with, but that still means we have to deal with it, right? We have to develop a workplace even in our own professions that will support working mothers. I think the AAP policy statement is more to push the system to set a North Star to support families than to guilt them into something. I think that is unfortunately misconstrued sometimes.

Hassink: As pediatricians, we spent our lives trying to learn how best to take care of children. We care and we know the parents care. In the pediatrician, parents have a partner to come and discuss these things. It’s not an authoritarian figure that’s going to mandate that you do things. It’s a partner to have a discussion. The environment is not friendly to children out there. It isn’t. The food environment is like a world of warfare for the families out there, trying to exist in a healthy way in our environment. The media, the food, the activity, the inequities. And I think parents have the task of saying, “How am I going to raise my child in a healthy way in this environment?” And that’s where the pediatrician can be your partner. If I could take one thing away from my families, it would be guilt, honest to goodness. I don’t know where the guilt came from. I think we all have some of it. It just seems to be amplified, this tremendous guilt.

Romper: When you’re about to release new guidelines, do you think, “OK, people are going to take this and feel bad about it, but it’s important to us to do it anyway.” Like, you must know before you publish that there’s going to be a million articles about how 13-year-olds should get weight loss surgery.

Hassink: The job is to present the evidence about what is helpful, what is healthy, what works. To not do that would kind of betray who we are. Some of the controversy we anticipated, like for the obesity guidelines, we anticipated some. We did not anticipate the firestorm.

Romper: Really?

Hassink: No, no, not at all. The guidelines triggered a lot of feelings in the culture over obesity, and the medicine and the surgery and so forth. That said, it’s providing an opportunity for us. Releasing guidelines is just the start in many ways, because then we have to do education around them for the pediatricians. We have actually been meeting with the eating disorder community in productive discussions and are going to be doing some joint education. There’s this rollout of education, of information, of dialogue, too, to really make sure the parents feel this is not a guilt-producing thing.

Bunik: It took years of vetting to put out the breastfeeding statement. So to think that we don’t think about it deeply…

I think unfortunately more and more now — and it probably happened during the whole Covid pandemic, when so much science was being questioned by officials — there’s an environment where some people mistrust medicine. And it’s going to take a long time for doctors to get that trust back and it’s not about breastfeeding or obesity prevention or obesity treatment. It’s about everything.

Romper: I think where some of the pain comes from is the idea of helping your kid change while also trying to help your kid love themselves at the same time.

Hassink: If you read the guidelines, the language looks pretty intense, right? But the conversation between a family and pediatrician is not like that. It’s a family-focused conversation about the health of your child and your individual child. Because the next step beyond the recommendations is tailoring those recommendations to the unique child and family that you’re working with. And often, to be honest, revolves around family history and risk in the environment.

Intensive health behavior and lifestyle treatment is always the foundation for obesity treatment and focuses on supporting the family in healthy eating and physical activity, addressing the effects of weight bias and stigma, encouraging a positive self-image and a family-centered approach to treatment.

For instance, if a family is eating outside the home frequently, the pediatrician may suggest gradually moving towards eating more meals together at home. If the child’s outdoor physical activity is limited due to neighborhood safety concerns, the pediatrician and family could work on indoor physical activity options. The pediatrician will screen for mental and behavioral health issues and risk for eating disorders as well as address any obesity related comorbidities that the patient has. If the patient meets the criteria for medication and or surgery, these options will be introduced to make sure that the patient and family are aware of all the evidence-based treatment options.

But it’s complex and it’s made much more complex by the weight bias and stigma in the culture. If this was a guideline about another disease, I don’t think we would have had that firestorm. We are working to remove blame and guilt from the parents. It’s just going to take work to help parents understand this. The saddest thing would be for a parent not to come to their pediatrician for help because of a fear of these recommendations.

There are many practitioners out in the field now that did not receive any education around obesity in their training, and we are busy, busy, busy putting out that education. This is a marathon, not a sprint. We don’t just pontificate. I have plenty of pediatricians that want the education the AAP provides, that want to do quality improvement, that want to increase their practice. I talk to them every day. Pediatricians have spent our lives caring for and wanting to help kids and wanting to work with you to do that, that’s what we want to do.