December 31, 2009

Television 3: Brave New World

Because I think television goes directly to our deepest unconscious, this post will have some provocative ideas I haven't heard before. Maybe you will have read it here first, and that seems like a good way to close out the year.

There's lots of evidence about all the correlations between TV viewing and all sorts of unfavorable impacts, some of which I have mentioned before. A few years ago, a friend from medical school told me about a study that showed that the more advertising a child was exposed to, the more they wanted fast food and popular toys. But this is a serious, deep bias.

Sure, we all hate advertising because it interrupts what we're focused on at the moment. And we don't like the idea that somebody thinks they can 'sell' us on something we don't already know we want. We really don't like the idea of some grown-up working for a multinational conglomerate selling something we don't want to feed or give to our innocent children.

But I think there's something else pervasive in advertising that hasn't hit the popular or political discourse on the evils of media exposure. It's the equally unrealistic positive portrayal of life. Typically the source of material for stand-up comedians, this outlook is what every ad agency wants to have you associate with their client's product. Maybe it's a frozen dinner that will result in your whole family sitting down to dinner together, including non-sullen teenagers and preschoolers for whom ice-cream would appear to be their only contact with meltdowns. The mother and teenage daughter who spend a leisurely walk on the beach laughing and sharing their tips on freshness. Yes, I'm very much making fun of these absurd caricatures of a life that nobody really has.

Television critics, however, can't have it both ways. There's lots of funding available to study all the ways in which television is harmful, exposure to media violence is harmful, exposure to advertising is harmful. It has so firmly become part of the common wisdom, that we take it for granted. So do the smartest scientists at the National Institutes of Health when they choose to fund these research projects.

There is no funding for researchers looking to show all the beneficial effects of television. Besides, they'd be risking their careers.

So though I made fun of the ridiculous way family life is shown in advertisements, those who have studied the effect on children have ignored this aspect of advertising. By their nature, most ads try to associate their products with the wholesome, healthy, happy, active and fun things we would all like to picture ourselves doing or being. If watching advertising is such a powerful negative influence, wouldn't these positive models be just as influential? If TV is such a powerful instigator of negative behavior, couldn't it also engender positive? All those situation comedies where people generally get along, family fights always end with a laugh and positive resolution within 24 minutes. The advertisements of siblings playing together, the family eating together, the teenagers being pals with mom and dad--why aren't these studied? If television is the powerful drug that many believe it to be, and if exposure to negative things shown on TV results in negative behavior (as is the conventional wisdom at the moment), shouldn't the positive stuff depicted result in positive behaviors? Here's a wild thought: if kids are watching as many hours of TV as it would seem, and it's a powerful influence, than just maybe we have better kids, less violence or negative behavior that we otherwise would have without the influence of all those positive models in advertisements and scripted shows where the family always comes together at the end.

And just because it's a drug doesn't mean it isn't therapeutic. Indeed, I have written again and again in these pages that my job is not to minimize the amount of medication a child gets. My job is to make them better. If it takes medication to get there, I'm for it.  It has become part of our modern lexicon to understand that many of us find ways, for better or worse, to self-medicate.  Sometimes this clearly often refers to serious untreated problems.  But it also includes retail therapy and chocolate therapy.  I propose that the giant elephant in the room of self-medication is television therapy.

Dr. Wolffe's Second Television Postulate:
If television is a drug, it could be effective, perhaps essential, for certain diagnoses.
If it is a drug, then it probably has what is generally called a therapeutic window. That's a way of looking at the dose of a drug. Too little, and there's not much chance of harm, but not much good effect, either. Too much, and the harm is more than the benefit. Somewhere in the middle is a dose that maximizes the benefit and minimizes the side effects.

Back in Television 2, I describe some of the children who are watching a lot of television. Whether caused by watching TV or the reason they watch so much TV, they are less active, fatter, and have poorer social skills. I suspect they are self-medicating with the television drug. It's a drug that addresses many different distinct problems. So if you're lonely and don't have a lot of friends, it provides some of the brain signals that you'd get from a non-judgmental friend. If you're depressed and can't stop thinking about how lousy your situation is, it boosts the chemicals in your brain that you might be able to get with a brief, small dose of antidepressant medication.

I wonder if it is actually underused as a drug. Maybe it's even underprescribed as a therapeutic intervention. That's not to say that kids should watch more TV. There are children who, at the end of their exhausting day, are tired and irritable, uncooperative and engaging in behaviors that show poor judgment, impulsivity, and oppositionality. Nearly every day, there's some sort of a blow-up around the same time. Do they have attention deficit disorder? They clearly have a problem with attention, but it seems to affect them only in the 45-60 minutes before dinner. Even if the kid's parent asked me to prescribe a medication for this, there's nothing that works so fast and lasts such a short time. Maybe this child needs 30 minutes of TV once a day before dinner. It starts working immediately. It redirects the child and will help focus attention, at least for 30 minutes or so. Five minutes isn't enough, five hours is too much. If we make this part of an unbending daily routine, and don't miss a dose, the child might look forward to this 30 minutes of television instead of flailing about looking for some undiverted parental attention, which is in short supply in the time just before dinner.
I know a pediatric dentist with small flat-screen televisions on the ceiling above each exam chair. Isn't it obvious why?

Why don't I have a video player the kids can watch—even if only for a couple of minutes prior to and during vaccinations? Wouldn't it keep the kids from ruminating anxiously about their shots? Wouldn't it distract them from the shots themselves? Why isn't there research on this?

Woody Allen, by the way, got to a similar place about 30 years ago. In his movie, Sleeper, he awakens after being cryogenically frozen for 200 years. His doctor offers him a cigarette and tells him that the newest research shows that it's the healthiest thing he can do.

December 28, 2009

Television 2: We have the technology

television-movie-4988 In Television 1, I pointed out that television is as much a part of our world as refrigerators or kitchen sinks with running water.  There are people who live without these, but they aren’t us.  And our kids probably won’t be them any time soon. Unlike common kitchen appliances, however, television, I believe, is a drug.

Dr. Wolffe's First Television Postulate:
Television is a drug.

Mostly for political and economic reasons, it has taken decades to get tobacco regulated as a drug.  Though used by Native Americans for ritual purposes long before Europeans arrived, it only became clear in the mid 20th century that this was more than a harmless pastime, like quilting or decorative embroidery.  These are gently pleasurable, help some people relax, and don’t hurt anybody else.  It's pretty tough picturing somebody holding up a convenience store in the middle of the night because they they finished their last skein of Pansy Purple #102 and they're feeling so desperate that they are willing to degrade themselves for the next fix.  It will be no surprise what the differences are, and I don't feel it's necessary to cite the references for tobacco use. So as you read the following list, try to think of it referring to someone in your family who:  smokes, gambles, exercises, shops, talks on the telephone, emails, texts, eats, diets, trades stocks, checks stock prices, reads news headlines, or collects something to such an extent that it has a negative impact on their health, appearance, close relationships, job, or life.

It’s addictive.
By addictive I mean that users can't stop whenever they want.  They do it automatically, on a very regular basis.  They feel bad and crave it when they don't use it.  They aren't the only ones who suffer--those close to them can see not-so-subtle changes in their mood, behavior, sleep patterns, and social interactions.  Many adults go to sleep with the TV on.  When it's off, they have a hard time falling asleep.  (It's not because it makes them sleepy--I'll write more of this after the new year in posts about bedtime.)

It can be harmful, even when used as designed.
There is a relationship between the level of harm and the amount you do.  Many people drink alcohol and don't have a problem with it.  Some people do have problems with it.  While there is research on the possible differences in brain chemistry or genetics between alcoholics and non-alcoholics, suffice it to say that some people find it very hard to keep to safe limits.  Ongoing recent research has examined problem gambling using some of the same methods.  There's some reason to suspect that people who can't stop eating the stuff they know is killing them, that exercise or diet or even shop to a level of self-harm have some fundamental neurochemical imbalance that compels them to do what they do.  Though there is much public hand-wringing about the harm caused by television, the research purporting television causing direct harm is deeply flawed.  But the epidemiology appears pretty clear.  Kids who watch more TV have fewer friends.  They do less physical activity.  They are fatter.  They eat more snack food.

Does the TV-watching cause these problems or do kids with these problems choose to watch TV?  I've thought a lot about this question, and I think for some kids it goes one way and for some it goes the other.  So, back to problem drinking:  for some, taking a couple of drinks impairs judgment and interferes with sound decision-making; for others, poor judgment and decision-making skills make them think that they don't have a problem with drinking.  So maybe the kids who have weak social skills or have never had fun by physical activity sit in front of the TV, they find there's something they can do just as well as the popular kids--maybe better.  There's something they can master and be authoritative about when with their peers (maybe Twilight or maybe it was Star Trek for you).  They can be completely open and unreserved with this nonjudgmental entity for which they are just as good a companion as their more successful siblings.  For them, it transports them to a safe and exciting world.  It also interrupts the stream of negative messages about failure, self image, popularity, and status that this child hears from others and from themselves.  It turns this endless loop off.  How, exactly it does this isn't entirely clear.  But the fact that it can suggests the converse question.  If a kid who doesn't have these weaknesses sits in front of the television for the 4 to 6 hours a day many kids watch TV, how might they be affected?  How ever many hours they watch, they aren't riding their bicycles or playing basketball in the driveway while they do it.  They are raiding the kitchen for snacks.  Even if they have a friend sitting next to them, they aren't practicing the subtle skills of social interactivity that make for popular playmates.  It changes what they do and how they act.  So either way, it's a drug.

It affects your body (including your brain).
Why does it calm the angry, tranquilize the oppositional, and make the rest of us into emotionally-blank drones who can't take our eyes away?  How, exactly, is that different from entertainment?  One difference, perhaps for some people (and children) more than others, is that the more you watch, the more you need to watch.  Television becomes part of your life.  When you travel, why do you turn on the television as soon as you go into the hotel room?  Do you let it play all night?  Why do we have to eat while watching (true for movies, too)?  I suspect that the hedonic sensation of eating reinforces the rise in calming and reassuring-type neurotransmitters that accompanies American Idol.  The research really isn't there yet to support fully the way I believe it works, but I think it's just around the corner.  It's very difficult for most people to stop the way they eat and lose the weight they know they need to lose.  No, it's not weak character or lack of 'willpower' (whatever that is).  Eating is so primal that the feedback we get from doing it causes deep and fundamental reactions in the parts of our brain that are invisible and uncontrolled by our intellect.  I think television pushes equally fundamental buttons.  Just like a drug.

December 25, 2009

Television 1: We don't have the technology.

 televisions broken china sepia Hypocrisy is the Achilles' heel of parenting.  Go ahead and hide it or deny it--your kids will find out.  They will find out that you have sex, that you don’t like one of your siblings, that you are depressed, that you read supermarket celebrity gossip magazines, and that you watch television.  Go ahead and try and hide it from them.  See how it works for you.  Here’s how it works for children.  They learn that you are intentionally deceitful.  That you lie to them and have been doing so for a long time.  Maybe they learn that you lie to your boss, your spouse, the IRS. Maybe they won't hold it against you, but they will learn from you.

In a previous post, I cited the good epidemiologic study which examined the sexual activity of teens who had taken a ‘virginity pledge’ compared with those who never pledged.  The pledgers initiated sexual activity at a younger age, and had more teen pregnancy.  Seriously, whose idea was it to have a teenager make such a pledge?  It doesn’t work.  These are good kids, who presumably made this kind of commitment to please their parents.  Or, at least what their parents said.

Here in Berkeley, there are plenty of families who don’t have a television, and make their kids play with wooden toys.  Among my favorite toys as a child were plain maple blocks that could be made into anything and couldn’t be  broken, couldn’t even be chipped.  I remember the LEGOs my parents brought  back from Denmark in the 1960’s.  Plastic, yes.  But it was just a box of uniform yellow blocks.  I could make them into anything.  Most construction sets are now marketed with precast purpose-designed parts. I think it takes less creativity, not more, to assemble the moonbase or skyscraper or castle out of these kits. Holding a piece of undifferentiated wood or generic plastic blocks and making zooming noises as it flies through the air is symbolic play at its best.

Still, it seems like a lot of the people I’ve met who have embraced this antitech lifestyle, who try so hard to compost whatever is left over from their visit to the farmer’s market, whose produce is carried home on bicycle panniers made of unbleached hemp fiber, live here.  And for the most part, nearly anywhere in the San Francisco Bay area is expensive.  How do they live?  Are they woodcarvers and henna artists?  Stonemasons and communal subsistence farmers?  There are no demographic statistics I can cite, but I live and work here and call it like I see it.  These parents are PhDs and knowledge-workers, making a great living from the service economy, high-tech industry, and new technologies.  Oh, did I mention the stock options?

The disavowal of technology in these families, I predict, will often not end well.  I think it’s likely that these successful, intelligent, well-off parents will probably sire intelligent kids that have all the advantages of growing up in a household with financial resources and high educational attainment.  But what will they think of their parents?  Every mobster’s kid knows how the family makes its money.  Why are these kids different?  Why are these parents ashamed of working for a Fortune 100 corporation?  If you’re a true believer, go for it.  Find some land and live off it, if you can.  You’ll need practical skills and knowledge that is hard to come by.  And you’ll need to work very, very hard.  Expect to be tired, and hungry, too.  At least your kids will eventually admire you for seeing one world and choosing a different one that is more meaningful to you.  (Think Amish.)  They will visit you in the compound/bunker and respect you for making a hard choice and being true to it.  Many times and in many contexts I have met adult children of parents who follow a strict code of some sort, usually religious.  Though the children have made different choices, the ones I have met mostly have no problem with the way their parents live, whether in Provo, Utah or Brooklyn, New York.  It’s the parents that are often intolerant of other choices.

There is also a curious denial of the ubiquity of television.  In New York, it’s in the taxis.  It’s in airports and some public transit stations.  It’s on your cell phone and laptop.  It might be on your watch.  It’s certainly in your child’s school, and every library.  Indeed, the grinding advance of electronic media suggests that books as we know them will be accessed on a screen by the time your little ones are doing research for their college term papers.  If you are deeply orthodox in some religion, it’s usually possible to find some educational institution to send your child.  Evangelical or Hasidic, Islamic, Catholic or Mormon, there are such places designed to facilitate your continuing enforcement of the walls you have erected around your child’s life experience.  Where will these children go?  To the university without computers?  Is that where you learned the skills you use every day to support your family?

Because of the insular quality that helps to define a cult, groups generally identified as cults have been heavily studied in social psychology, sociology, and other fields.  One important aspect of a cult is limitation of interaction with people and institutions outside of the cult.  I worry that the children without television will have some social limitations.  Will their parents limit their playmates to those living in similar households?  That sound fairly restrictive.  Will they be able to see TV at their friend’s house but not at home?  Won’t that make the parents appear hypocritical to the child?  Since they can’t share typical topics of conversation for kids--characters in the media, popular anything (music, TV, movies, games)--will they seem odd and out-of-touch to their peers?  Can you really limit their friends to members of this same cult?

It may sound like I’m in favor of wiring a cable box directly into the crib.  Not true!  I love those wooden blocks, and encourage their use (as long as they are from sustainable species).  This post is a warning to parents about the difficult line they draw with dogma.  The more rigid the belief system, the brighter and more inflexible this line is.  My concept of empathic parenting embraces the individuality of a child’s needs and talents.  Forcing every child’s unpredictably-shaped peg into a rigidly uniform hole seems to me likely to injure a lot of kids.

For more on the topic of television, stay tuned.  Same bat-time, same bat-channel.

December 22, 2009

Television Rules and Concrete Thinking

concrete mixer A parent recently asked me for advice about TV.  She said that they had just moved, and in the past few weeks, it’s been blissful living out of boxes with the TV not yet unpacked or hooked up.  They aren’t fighting with their 6th-grader about limits on viewing time, and all the things that go with it.  Her 12-year-old keeps asking about the television, however, and her husband is going to try to set everything up over the weekend.  What should she do?

She’s not particularly afraid of the content of what her son watches.  He’s a smart, nice kid who does well in school.  She’s more concerned about the hours he can spend doing nothing else.  She is not looking forward to the inevitable fights about limits on screen time, limits on times that he can watch, limits on TV when his homework isn’t yet done, and so on.

One issue is his age.  At 12, kids do a lot of concrete thinking (see Visit to The Other Parent).  That means that vague rules about priorities (homework is more important than television) are not as effective as concrete rules (no television until math homework due the following day is done).  So the rules have to use this inflexible way of looking at the world.  And they can’t be made up as you go along.  To the child (and to me) that will see capricious, arbitrary, punitive.  So the best way to make rules might be collaboratively, with the child actively involved.  Have a family meeting on the night before you unpack the box.  At the meeting, ask him what he wants and what he thinks you want.  Then ask what he thinks you’ll settle for.  You might be surprised at how realistic he is.  So I don’t anticipate a big fight when the rules are put to paper.  The same concrete thinking reduces his capacity to project scenarios ahead in which he would very much be interested in nagging you for an exception to the rules.  So fights over TV tend to arise at the time of the child’s temptation (when they want to watch something or play a video game, but their homework isn’t done or there’s some other commitment).  These conflicts don’t usually occur in the drafting session, when the rules--though worded concretely and specifically--require abstract thinking to foresee their application.  From a business negotiation point of view, this gives you an advantage in the formulation of the rules.  If you don’t do this, and let it go until his TV show is on and his big project is due tomorrow, he will have the advantage in the negotiation.  Even though it might not end well for him, there could be a considerable amount of bad feelings all around.  Keep the language simple, keep it to one side of one page.  Frame it, under glass.
break glass to release button
  In Emergency, Break Glass.
Oh, one more tip for concrete-thinkers:  rules are made to be kept, not broken.  He’s having friends over?  It’s Christmas?  The math homework still has to get done.  You can use his concrete thinking for his advantage and yours, by collaborating on (not imposing) some specific rules.  But those same concrete interpretations of the rules will conclude from every exception that arises that the rules are flexible with your mood/your whim/your schedule.  In other words, there are no rules at all.  Consistency is credibility in concrete thinking.

A lot of parents find rules easy to make and hard to keep.  They figure they are grown-ups and get to do what they want.  Well, in most ways, that’s completely true.  Do what you want.  But now that you’re a grown-up, you should know that there are consequences for your choices, and you should be able to anticipate most of these.

So in the example I’ve been mentioning, he is not allowed to watch TV until the math homework due the following day is done.  OK, he did it.  (How do you know?  Are you aware of his assignments?  Have you asked the teacher if he’s behind on turning homework in?  Does he need help with math?)  So, according to the rules, he’s allowed to watch TV for, let’s say, an hour.  But he still hasn’t cleaned up his room, and you asked him to do that a week ago.  Do you tell him he can’t watch TV?

Assuming you come up with some TV rules that you both agree to, have him sign the paper.  It’s probably the first contract of his life.  Every contract has a term.  (We know how long a marriage contract, for example, is supposed to last.)  So put an end date on the rules, and agree to revise them at the end of the term or some other natural date.  You have to sign the paper too.  When you do, know that this is not a parenting idea.  It’s your credibility with your kid.  Sure the rules may appear to be about him and his TV privileges.  But they require you to comply also.  Your enforcement tool is your power to disconnect the television.  His enforcement tool is his power to distrust you forever and not speak to you for the last 50 years of your life, keep your chicken2grandchildren from you, and make you pay for college tuition—for your therapist’s kid.   Do you really want to play chicken?

It never ceases to amaze me that the most insightful parents lose sight of this basic truth.  I’ll ask them about the things their parents did that most bothered them (and might bother them still).  They—you—remember these actions vividly, even 20 or 40 years later.  So why is it such a mystery when your kid is bothered by you doing it?

So can he watch TV or not?  Stay tuned.

December 18, 2009

Visit to The Other Parent

We have the technology.telephone3c At holiday time in particular, when school is out for a substantial amount of time, many of the children of divorced parents get to spend some quality time with the other parent.

A stepmother expressed her worry about this.  She said that  Luke, 13, is very excited about spending the holidays with his mom, who lives an airplane ride away.  She said that Luke has often said how much he misses her.  Despite this, however, she also notes that his mother doesn’t call, doesn’t write, doesn’t email.  His mom is not involved in his life.

Life at 13 is difficult.  On the one hand, kids this age can smell and taste the benefits of adulthood.  If we would let them, they’d drive.  So they see attractive things on the horizon that they believe they are perfectly capable of doing.  But they can’t quite figure out how to get from here to there.  They have no idea that to become a doctor (I get this question a lot), you actually have to spend a lot of time in classrooms and do a lot of homework.  Another problem that nearly all 13-year-olds share is concrete block concrete thinking.  You tell her to call if she gets out of school late.  She doesn’t call, it’s 8pm, and you have the police out looking for her when she walks in the door and asks what all the fuss is about.  ‘Why didn’t you call?’ you ask in the calmest tone you can pretend.  She answers that she was supposed to call if school got out late.  It didn’t.  She left school right on time, then went shopping with a friend.  She followed your directions to the letter.  But she missed the forest because all she could see was the one tree.  This kind of thinking leads to parental frustration and these younger teens thinking that their parents don’t understand them at all.  Maybe they’re right.

As the child gets to this point, like a scenic overlook where they binoculars_for25ccan see adulthood in the distance (but hopefully not with those awful binocular machines that always steal your 25¢  and never work right),they try to distance themselves from their parents and move closer to their peers.  This is a normal developmental stage, but it’s hard on the parents who can feel that they are losing the child.  If the parents hold on tighter, I usually see a much worse outcome in the long run.  You can’t hold back the tide, either of the ocean or of your child’s independence.  If you try, the end result is typically resentful and rebellious children who may or may not talk to you after they leave your household.  They will be independent whether or not you try to restrain them.  Why not make it work for the two of you?

Luke has concrete thinking.  So I worry that it has not occurred to him that something is wrong with this picture.  His mother isn’t in contact with him.  You, dear reader, are either a mother or have met one at some point in your life.  Does that sound right to you?  I don’t know if the problem is the mother’s alone (illness of some kind, including mental illness; substance use; shame or economics (can’t afford to call or visit, can’t write a letter, is embarrassed by meager circumstances compared with ex-spouse)), or if the father has explicitly or in some subtle way discouraged contact perhaps by intercepting letters or restricting phone use.  No matter what the reason, there’s a serious problem here.  Whatever Luke thinks life with mom--even for just a couple of weeks--is going to be like, he’s wrong.

This is the advice I gave.  We’ll see, after the holidays, what actually happened.

I suggested that his dad and stepmother give Luke a cell phone before he goes.  (If you think this is too indulgent, maybe you can find a fat bearded guy in a red suit to give it to him.)  This is really important.  It gives him a way to call you without using his mother’s phone, and without asking her permission.  It also gives you a place to call every day without leaving a message on her answering machine, without having her accuse you of interfering.  Most importantly, CALL HIM EVERY DAY.  Don’t call multiple times, don’t ask the minutia of what he did with mom as if to second-guess all of her decisions and plans.  (If that’s your goal, get help.)  The purpose is to tell him every day that you’re thinking of him, that you miss him, that you love him.  Don’t ask him anything.  Not even one question.  You are just calling to tell him that short message, not ask anything of him, nor interfere with his relationship with his mother.  He may say he doesn’t want you to call every day.  You might want to do it anyway.

Luke is one of my patients with ADD.  So I had further advice for his stepmother.  Get a second, prepaid cell phone.  Write down the serial number and all the numbers inside the phone, and the activation instructions that came with the phone.  Then, James Bond-like, sew this brand new but nonworking cell phone into the lining of his suitcase.  Ideally, without his knowledge.  Then, after he loses the phone you gave him, he will have one right there.  All he needs to do is call you, get the activation instructions, and turn it on.  Maybe you can even do it remotely.  He’s going to lose the phone you gave him.  So get over it now, be prepared with the online tools or toll-free number to turn off the lost phone.  Don’t blame him for it!  How can you blame him from something you knew was going to happen by reading this very paragraph?  You, dear reader, have been served.

OK, for those of you a little more domestically challenged, maybe you don’t have to sew it in the lining.  But sneak it in the bottom of his bag.

I know that once he’s got a cell phone, it will be tempting for him to use all the available airtime texting his friends.  Get a plan with expensive texts and tell him you will take the cost out of his allowance.  Or turn off the text function altogether.  As the owner of the phone, you can turn this feature on again if you need it by phoning the cellular company.

Do NOT tell him to call you at all.  If he wants to, he will.  If you want him to, he won’t.  If you force him to, he’ll resent doing it.  If you don’t want to follow my advice to call him every day with a quick ‘I miss you’ message, don’t tell him you will call him every day.  Never, ever, tell children this age you will do something that you don’t actually do.  They will remember it for the rest of their lives.  More on this later.

December 15, 2009


States-of-Matter taylor elementary
Of the approximately 100 members of my class at Yale School of Medicine, every single graduate—100%—were eating solid food.

With that admittedly anecdotal experience, I have reassured many parents that at some unpredictable point between 4 months of age and medical school, their baby will—I virtually guarantee it—eat solid food.

Jamie, barely 4 months, used to sleep 6 or even 8 hours at night last month.  But as the weeks went by, he was awakening more often.  His parents said that he’d get a good nursing at about 10pm and then he’d be out for about 3-4 hours.  Then when he awoke, he’d nurse again, out for 2 hours.  Then 1 hour intervals through the rest of the night.  The nursing was sometimes 15 minutes, sometimes 30.  What was happening?

Unlike The Human Pacifier, this 4-month old appeared to want to eat.  He wasn’t looking for reassurance or comfort during the night, he was really nursing.  There’s a behavioral aspect to frequent awakenings, that can become a problem as babies get older.  (I hasten to add that there’s no crying baby who doesn’t need attention and care.  Maybe there’s a sleep problem or a behavioral issue, but the approach to this should never include ignoring the baby, even if it does include a measured response.)

There’s no way to untangle the comfort provided by nursing with mommy in the middle of the night from the baby’s hunger.  Or is there?  In the 3-part Human Pacifier series [part 1, part 2, part 3], the baby was waking up to nurse for a minute or two, sometimes less.  He’d go to sleep right away after just a moment or two of snuggling with mom.  But Jamie’s mom didn’t have it any easier.  She, too, was getting up nearly through the night.  This baby was nursing pretty much to the capacity of the mother’s production.

Here’s what’s going on.  The baby is full when he’s going to sleep.  That’s why he has his longest sleep immediately after that last big feeding.  He was about 2 pounds less a month ago—that’s a big proportion of his body weight.  At the time, it was enough to keep him nearly through the night.  Now, it’s enough for 3 hours, maybe 4.  Then he wakes up hungry.  Nursing for 15 to 30 minutes is enough to take the edge off his hunger, and get him back to sleep.  It’s not enough to fill him.  The less-than-enough feeding may take the edge off, but it’s not enough to last long.  So this second feeding doesn’t last as long as the first.  He wakes up and mom does her best.  But 2 hours later, he doesn’t get the same amount he got after giving mom a 4-hour break.  Her manufacturing apparatus just isn’t set up for just-in-time inventory management.  He’ll get just enough to take the edge off again, but this time wakes up in an hour.  This is much less time than the factory needs to meet demand.  So from this feeding until morning, both baby and mother are locked in lactational Reaganomics—a trickle-down model of infant feeding.

So there’s a couple of logical approaches, with both possibly rooted in an econometric, perhaps even game theory perspective on infant rearing.  Isn’t this the approach most parenting authorities take?

First, we can decrease demand to match supply.  It’s hard to see Superman taking valuable time from his busy schedule and presumably many other commitments to fly really fast around the planet backwards and so turn back time to when the baby would stay full through the night.  There’s some ambiguity about how Superman ages, since he progressed from baby to newspaperman quickly but hasn’t changed much since the 1950’s.  I mention this because he’s going to have to accomplish this same task every month forever if we’re really intent about restraining the baby’s growing demand.

So, like true Reaganomics devotees, we need to focus on the supply side.  Here, there is a fork in the road.   There are many ways to try to increase milk supply.  This is a reasonable way to go, for a while.  Babies, however, can be relentless in their ever-increasing demands.  Will they never learn?  The other fork bypasses this captive supply chain and outsources the inventory management.  This baby was ready for solid food.

Human milk is really easy to digest.  There isn’t much else that goes through a baby’s stomach faster.  Solids get digested much slower, so they keep the baby full a lot longer.  For the record, the calorie content of solids is typically much less than breast milk or formula—so I don’t rush to start solids in babies who are having problems gaining weight.  Not every baby takes to solids right away, but the level of stress this induces occasionally confounds me.  I think of my fellow graduates and for god for country for yalecan’t think of a single one, not one, who wasn’t eating solid food.  I can’t authoritatively say that this was true at other medical schools, of course.

December 11, 2009

Patient Zero: The Hundred-Day Cough

Andy is about the healthiest 11-year-old in my practice.  If he didn’t keep bruising himself playing basketball, I don’t think he’d ever come to the office.  The cough he had was remarkable for another reason, too.  He wasn’t sick.  No fever, no trouble breathing.  No noisy breathing, not even a runny nose.  He didn’t even cough most of the time.  But every 5 or 10 minutes, he would cough and cough and not be able to stop for about 2 minutes.  During the 2 minutes, he had a lot of trouble getting a breath in between the coughs.  He only had this for a few days, however, so he got some cough medicine that helped to suppress the cough, and that helped him.  He was over the worst of it in a few days.

I’m fortunate that my patients and their families often recommend me to their friends.  So Andy’s best friend David was in the office the following week.  He had asthma, so his cough was just the latest in a series of exacerbations.  I increased his asthma medication, and he improved.  For a while.  Then he went back to coughing.  So he was back in the office, this time with what sounded like pneumonia.  He got antibiotics, and more asthma medication, and he improved.  For a while.  The cough he had was peculiar, and seemed to come in fits, just like Andy’s cough.  Sometimes, one of these coughing fits would stop right after he threw up.  For one visit, he and his mom brought along Sean, a friend from school.  Sean waited politely in my little waiting area.  After the first month of symptoms, two courses of antibiotics, tons of cough and asthma medicine which seemed less and less effective, I got lab tests.  He wasn’t thrilled about having to get a blood test.  On the way out of the office, he introduced me to Sean.  Sean was coughing, too.

  Though finding infective bacteria wasn’t likely after the antibiotics he received, I knew what I was looking for and ordered measurement of the antibodies in his blood against pertussis.  In the 19th century, it was sometimes called the Hundred Day Cough.  The kind that show a long-term memory in the immune system, IgG, would show a healthy response to his series of infant immunizations.  Another kind that I requested, IgM, would be evidence of an ongoing or very recent infection that his body was trying to fight off.  His pertussis IgM was very high.

After calling his parents to tell them that I had a diagnosis, my next call was to the office of Public Health.  Within 12 hours, they were mobilizing in one of the local middle schools.  David has an older brother in high school.  He was coughing, too.  Within 24 hours, they were at the high school, too.

Andy’s mom told me that she felt bad about him starting this growing number of cases.  It wasn’t anybody’s fault, I told her.  She knew about epidemics, and she called Andy Patient Zero.  Patient Zero is the very first case in an epidemic that can be identified.  All the other cases can be traced back to this one.

By Halloween, a couple of months had passed from the time that Andy first came to my office.  He wasn’t coughing any more; David’s older brother wasn’t coughing any more; even David wasn’t coughing any more.  I was at their house for a party on Halloween.  (I dressed up as a pediatrician who stayed late at the office. )  Andy’s friend Sean was there, coughing. 

I was introduced to Sean’s parents, who, in a friendly way, tried to explain that their decision not to have Sean vaccinated was just a personal choice, like being vegetarian or buying fair trade coffee.   Sean wasn’t my patient, and I left the conversation.

I pulled Andy’s mother aside and told her that he wasn’t Patient Zero.  Sean was. 

Given that unvaccinated children are 23 times more likely to get pertussis, it’s pretty likely that in my neighborhood, the kid that gets it first is probably unvaccinated.  David, who has asthma, really struggled with it and needed a lot of medication that he probably otherwise would have been able to avoid.  Sean too, I suspect, was suffering.  He had been coughing for about 2 months or more by Halloween.  In vaccinated kids, the mean duration of the worst cough is 29-39 days.  In the unvaccinated, 52-61 days.  That’s an average, so some will be longer and some shorter.  The incubation period for pertussis is 4-21 days.  Sean was the first to have the disease, and is probably spreading it even now, with every frequent cough.

Sean, I assume, and the 3 of my patients who got pertussis from him, will all be OK.  But when they come home from school, who gets it from them?  What about the grandparent with lung disease?  What if there’s a sibling getting chemotherapy?

Andy’s mother is pregnant.  When the newborn is home in a couple of months, will Sean come over to hang out with Andy and David?  How will she make decisions like this?  When I told her that it was nobody’s fault, I didn’t know what I know now.

December 8, 2009

Rule #6: Dr. Wolffe's 'Baby' Rule

First, an editorial note. I don't know if this is really rule #6. I think if I had called it rule #1 then it would seem to be the most important rule out of however-many rules there turn out to be. Rule #2 will have you wondering what is the rule that is so much more important than that. Rule #79 seems more like a guideline than a rule. I will post other rules as they arise, and will have to see where their numbers unfold.

6.  Dr. Wolffe's Baby Rule:  
Never apply any product to your baby that has “Baby” in the name.

Simple, right? Hospitals often give out free samples of products covered under Rule 6.  Feel free to use them on yourself. Don't start with that blame-the-drug-companies stuff, either. Pushed equally hard, and at considerably higher prices, are many product lines of 'natural' products targeted for use on babies. Are these products natural? In fact, they are designed to be marketed to parents who really want to use all the products covered under Rule 6, but who feel better about themselves by buying the products in a purportedly greener venue. I'll go through the usual suspects:

  1. Baby Shampoo. If your baby has any hair at all, how dirty does it get? Dreadlocks—I don't think so. Dripping with sweat from being overambitious on the stair-climber in the gym after work? Not likely. If your baby has cradle cap, especially if it's severe cradle cap, the baby might need a prescription shampoo. Baby shampoo won't help it.

  2. Baby Wash/Soap. You know that car that's jacked up on concrete blocks and wire milk crates in your front yard? The one that your neighbor applied for a court order to have you remove because it was bringing down property values? Let's say you're under that car replacing the starter motor that burned out when you let that dim cousin Dale (though everyone calls him LD which stands for 'Little Dale' because everyone calls his father Dale) use the car briefly in 1997 and he ground at least two teeth off the starter ring gear.  You're being a conscientious parent,

    watching the baby, who you have next to you on the wheeled creeper under the car. Loosening the transmission fluid cooling lines sends a gush of dirty transmission oil all over the baby. Now you're going to need some soap when you bathe the kid. Until that happens, however, nearly everything else that gets on the baby will come off with plain water and gentle wiping with your bare hand.

  3. Baby Oil. What is this stuff, anyway? How exactly are babies industrially processed to extract their oil? Is it refined? Crude? Extra virgin? It turns out to be mineral oil, refined from petroleum, plus fragrance. Your baby needs fragrance? If your baby smells unpleasant, that's a signal for you to be taking some sort of definitive action to remediate that issue.

  4. Baby Lotion. There's an old-fashioned expression: smooth as a baby's behind. How did it get that way? Not from lotion, I assure you. There are babies who have dry or problem skin. It's hard to imagine that a baby with very dry and sensitive skin is somehow going to be helped by a mix of heavily-fragranced, colored, saponified organic compounds. If you buy the 'natural' brand, it will probably also have calendula in it, which can really do some damage to sensitive skin. (See my post on this topic.) On a related note, the peeling skin of a newborn has nothing to do with the skin being dry. Everybody's skin would peel after a 9-month bath.

  5. Baby Powder. Powder is by definition dry, so is indeed a logical choice for absorbing liquids. Will it keep the baby dry? Do this yourself—put some in your hand and see what happens when you add a little liquid. Does it absorb much? Or does it turn into a strongly-smelling congealed abrasive? And what, exactly, happens to that cloud of particulates that seem to linger in the air that you and the baby are inhaling?
If this has left you feeling like you have to throw away your entire shopping list, don’t despair.  Here’s a Baby product to put on the list.
baby grand piano
And there’s always this.

December 4, 2009

Looks Like an Attention Problem: Part 1

The official diagnostic criteria for ADHD require that symptoms start before age 7.  In boys, particularly the hyperactive ones, they usually show up in my office while still in elementary school.

So I was skeptical when I met Franklin, 15 years old and brought at his own request for an ADHD evaluation.  Most kids don’t think there’s something ‘wrong’ with them.  Parents are reluctant to think this too, and most don’t want to think that their child might benefit from medication.  So in the context of both patients and parents reluctant to get this diagnosis, I couldn’t help but wonder if this teenager had a substance problem.

Indeed, his mother admitted that he had been requesting this evaluation since 7th grade, but his grades had been good and his mother couldn’t imagine that something could be wrong.

But I have to admit he looked the part.  Rail-thin, and constantly in motion.  When his knee stopped moving, his fingers would tap.  He fidgeted constantly in his chair.  I asked about what his classroom work was like and found the same classic answers.  He could do the work, but often forgot that there was an assignment, forgot to hand in assignments he did, and never knew when there was going to be a test.  His mother bought him an organizer.  Then another and another as he lost them in series.  When asked about a family history, she took the opportunity to  tell me that his younger sibling had no such troubles, and excelled in school.

In his favor, he hasn’t been a conduct problem.  He wasn’t constantly being sent to the principal’s office.  I sent them home with questionnaires for parents, teachers, and Franklin.  But before they left, I told his mother that I wanted to talk with him privately.

As fidgety in private as he was with his mother in the room, he told me that he was frustrated by attention issues.  He wanted to do his homework, but every time he sat down to do it, he’d end up in another part of the room, doing something else—within just a few minutes.  But the more he described the attention issues, the more his voice changed, and his face changed.  I asked him about depression symptoms, and he paused.  He thought he was depressed.  I asked if he thought about suicide.  He said he did, but didn’t everybody?

The questionnaires came back with a clear concentration of attention problems.  When I asked them about his attention symptoms, they clearly did start long before he was 7.

Though I think ADHD is too casually diagnosed and managed too haphazardly, it has been treated and studied for decades.  So there are really good data showing that careful medication improves just about everything.  Unmedicated teens with ADHD have higher rates of dropping out of school, substance abuse, suicide, failed relationships, teen pregnancy, and many more interactions with the criminal justice system.  So for the right person, in the hands of the right doctor, these medications are life-changing and are extremely effective.  Franklin’s core attention symptoms were so focal that I thought he would really benefit from a medicine that addressed these symptoms directly.

But I told him directly that the fact that he had been able to get by in school so far made me very optimistic that we’d figure out the attention part at some point.  But at this moment, I was most concerned about his depression.  I told him that I wanted to treat that first, and when the depression was under better control, I’d focus on the attention.  With his permission, I explained the plan to his mother.  He looked tremendously relieved.

In Franklin’s case, his attention symptoms were quite specific.  He was impulsive, forgetful, disorganized, hyperactive, and unfocused.  It would have been easy to treat this directly, and probably would have helped him feel better.  But I was worried about him, and that makes all the difference.

Depression, unlike Franklin’s attention problem, is not a focal problem.  It’s a pervasive stain that taints all the aspects of a persons life.  When you’re depressed, things planned for a couple of weeks in the future just don’t matter.  So they lose their importance.  If you don’t think that your life is going anywhere in 5 years, what possible meaning could the test in school have for you?  Why would your homework matter?  And if your class lapses even momentarily into boredom, paying attention to anything else seems like a perfectly logical choice.  As depression gets more severe, this time horizon gets closer.  When it doesn’t matter what happens that day or that hour, there’s not much that will motivate you to organize a whole semester of assignments.

I prescribed an antidepressant, which fortunately took effect within days.  If his mood stabilizes, I’ll start him on an attention medication.

The photograph at top is a portrait by Felix Nadar, the finest French portrait photographer of the 19th century.  It's of his son.  Except, perhaps, for his clothing, it is certainly a completely modern photograph.  It is in my collection, and used to belong to Andre Jammes.

December 1, 2009

The Thanksgiving Sleep

ThanksgivingFeast-negative One of the persistent questions that come up at Thanksgiving, by well-meaning distant relatives trying to fulfill their annual social obligations by making conversation with the doctor in the family, is why turkey makes people sleepy.  Is it, they wonder while showing evidence of scientific literacy, because of all the tryptophan? 

I typically answer that it's an interesting question.  As questions go, however, it's really not that interesting.  But I, too, have my annual social obligations.  So helping other people fulfill theirs helps me fulfill mine.

Even without the burden of family relationships, however, this question is a relevant one not just because of the recent holiday but also because of some research studies I've been reading that leave me both interested and disturbed.

No, it's not the turkey.  Turkey does have the amino acid tryptophan in it, but no more than many other foods.  It's the gigantic overeaten orgiastic tsunami of food that makes us sleepy.  The more stuff we have to digest, the more our bodies move blood flow to our intestines.  That leaves less blood for less essential organs such as, for example, the brain.  In order to metabolize just one slice of pie (though there were, to be fair, 3 different types of pie and a cake of some sort; so it was just one slice--of each), our body has to pump insulin into our bloodstream.  That can cause fluctuations in our blood sugar that leave us very sleepy, too.  So if you think that the vegan tofurkey is going to sharpen your wits, it won’t if you eat the same excessive amount of it and everything else as your mainstream relatives do.  Here in Berkeley, needless to say, one has the luxury of access to exotic and gourmet foods.  And to foods like tofurkey.  (For readers na├»ve to the special experience tofurkey provides, I would guess that fewer people choosing this product for thanksgiving end up as profoundly overindulgent at the thanksgiving feast.  Whether this is because of superior self-restraint or inferior sensory experience of the food itself would be a matter of speculation.)

Tryptophan is not manufactured in the body, so it's called an essential amino acid.  But it's in lots of common foods, so we usually get plenty of it.  In the body, it's used for many purposes, including the production of the neurotransmitter serotonin.  Serotonin also has many functions that we know of, and seems to be very important in the regulation of our mood.  Many antidepressant medications are designed to increase levels of serotonin.  There are several over-the-counter tryptophan products available at the drugstore.  But it's not a feel-good pill.  Too much serotonin can cause tremors, blood pressure problems, muscle damage, and worse.  This is called serotonin syndrome.  That's assuming that the tryptophan product isn't contaminated in some way.  Twenty years ago a new disease emerged called eosinophila-myalgia-syndrome.  Though symptoms varied, probably over 1000 people had painful symptoms and a couple of dozen died.  All had been taking tryptophan.  Tryptophan is sold in the United States as a supplement, unregulated.  It's sometimes sold as something to help you sleep, since so many people believe it's the component in turkey that causes sleepiness.  And some of the tryptophan is converted to serotonin which is then converted to melatonin which helps some people get to sleep.  How much tryptophan do you need to take to increase your melatonin levels enough to have an impact on your sleep?  Given that the tryptophan in your thanksgiving turkey isn't what's making you sleepy, it might be quite a bit.

None of this is the research I read.  What I found out about was the appealing idea of adding tryptophan to baby formula and baby cereal.  The idea is straightforward enough.  Feeding the baby the right product at bedtime could be helpful in keeping the baby asleep longer, and everybody is happier.

But I worry about a baby getting one of these nasty syndromes.  How much additional tryptophan is too much?  Both human milk and cow milk have about the same proportion of tryptophan, so either formula or nursing is likely safe in this regard.  But extra?  Of course there is a philosophical objection, even if it were completely safe.

Babies cry.  It's one of the main ways that they communicate.  They have other talents, to be sure, but they often cry when the need something from us.  Given that it may be inconvenient and frustrating to try and figure out what it is that they need, it has always been tempting to find a way to 'help' the baby stop crying.  There's a big difference between getting the baby to stop crying and meeting whatever its needs might be.  In the 19th century, there were several very effective nutritional supplements and tonics marketed for quieting babies.  The opium in them seemed to help right away.  It suppressed hunger, reduced pain, caused sleepiness.

I'm not claiming that tryptophan is equivalent to opium.  But I ask myself, 'who is this helping?  What patient am I treating?  Is the baby going to be better because of this?'  So, for now, I'm suggesting that parents resist the urge to give their babies extra tryptophan.  Wait until the kid can just eat turkey like the rest of us.

November 26, 2009

Giving Thanks

Dear father and mother, I know
I cannot your kindness repay,
But I hope as the older I grow
I may learn your commands and obey.

You loved me before I could tell
Who it was that so tenderly smiled,
And now that I know it so well,
I should be a dutiful child.

 --from a sampler by Fanny Kitson Newman, London 1832, age 6.  Yes, 6.
I like courtesy. Manners, at their core, are culturally-filtered actions that confirm the empathic nature of human interaction. OK, I'll try to put that another way. When I hold a door open for someone, and they walk through, it's nice if they say thank you. Superficially, it would be considered plain good manners. But at a deeper level, the person is acknowledging that I did something that took thought and effort, that I delayed my own journey by a little bit to make theirs a little easier. They get that I didn't have to hold the door.
Yes, it bugs me when I do this and somebody walks through the door without a glance or word, as if it were my job. And by the way, that's not enough. As if all of us haven't had our shares of thankless jobs or ungrateful bosses/ employers/ clients/ customers, getting paid does not take the place of simple, empathic, courtesy. We should thank people for a job well done.

How do we teach this kind of behavior to children?

This is a much more complicated question than parenting books would have you believe. The complication results from the understanding that each child brings to these interactions their own social programming and intuition, governed by a wide variety of influences from brain chemistry to sibling birth order. As with my perspective on parenting in general, there is no one right answer.

That being said, there are clear wrong answers. The parent who punishes the child for what is perceived as bad manners does not effectively teach the child to be polite. They may indeed condition the behavior they desire. We can indeed physically intimidate most children to get them to perform whatever tricks we have in mind for them to do. It changes a behavior without teaching any knowledge or understanding that can be applied to different situations when the threat isn't there.

For those of us who didn't go to Dartmouth in the early 1960s, an instructive documentary film provides a glimpse of a typical hazing ritual that culminates in the repetition of the phrase, "thank you sir, may I have another?" I advise all parents of college-bound children to obtain a copy and study it, in private.

Children, I believe, are a lot smarter than we often give them credit for being. They usually know--or eventually find out--when we're lying to them. It is particularly insidious to make them lie for us. That's a great way to teach them what dishonesty is and how casually we employ it.

So it continues to bother me when it unfolds in my office. One of the very least favorite things I have to do in my job is perform a painful procedure. Whether it's giving a shot or taking out a splinter, draining an infection or just finding out where it hurts, I don't look forward to it. Kids, of course, are not usually trying to repress their feelings, and are often refreshingly open about how they feel about the unpleasant activity. No good parent wants to see their child in pain and no good doctor wants to cause it. So why is it that many parents make their child say thank you as they are leaving the office?

It's fine to remind your child to say thank you after getting a lollipop. Maybe they need a little coaching to ask for one with a please. But being grateful for a shot is too much like thank you sir, may I have another.
It's true that courtesy becomes a habit and rote repetition will reinforce the habit you'd like your child to acquire. But it's the empathic foundation of manners that will actually make them into courteous people. We need to teach that. Here are some of the ways to do it.

  1. Notice them being good. It never ceases to surprise me how often children will occupy themselves quietly while a parent and I engage in important but incomprehensible conversation, and the parent doesn't notice! I really try to thank the child for helping by letting us talk about things. I tell them how great it is that they put away the blocks, or looked at the book. If there is one universal failure of parents, this is it. Like the parents of Fanny Newman, we simply expect excellent behavior. How is that different from our ungrateful boss, who simply expects our superior work product as the norm and neither notices nor rewards it? Why do parents expect their kids to do stuff without thanks? So much of what I do with behavior is managing rational expectations. You made the decision to have children and if you expected them to thank you for the privilege, your goals need to be adjusted. Seriously. If you want them to be speaking to you when you're old, you need to start right now. I have nothing against assigning them duties around the house—but if these chores get done, you still need to say thank you. Every single time. Even if it's a uniformed doorman who opens the door for you, thanking him says so much—especially if you're with your child. We need to re-train ourselves to see what's right in front of us, the child who's doing something right. And don't wait around for the kid to be doing everything right. I promise they are doing lots of things right, so don't let a day go by without thanking them for something real.

  2. Point out to them when somebody is helping them (or you). Though shopping and getting around in general can be quite an inconvenient hassle with a child, every parent's life is filled with the kindness of strangers who give up their seat on the bus, hold one of the grocery bags, or otherwise lend a hand when it's obviously needed. You might thank the person, but did you explain it to your child? Did you say it really helped us when that lady gave us her cart. That's why I said 'thank you'?

  3. Tell them how it makes you feel. Every child wants to please their parent, and they want to learn how other people do it, too. So when it's you that gets thanked for bringing over a pie, don't miss the opportunity. Tell your child that it made you feel good when you were thanked for it. You might be shocked how often your child will notice things to thank you for once you explain how this works.

  4. Don't force them to give thanks for stuff that hurts. It's not courtesy, it's counterproductive Dickensian brutality that will just teach them that these basic expressions and words are meaningless. So in #1 above, when you thank them for something, it's got to be something they know is honest. Thanking them for being 12 or for doing something you made them do (like getting shots) is not going to leave a helpful impression on an intelligent child of nearly any age.

Thanks for reading.

By the way, I found the full(?) text of the poem.  I haven't been able to find an author, so if anybody knows who wrote it, please share.

  My father, my mother, I know,
    I cannot your kindness repay;
  But I hope that, as older I grow,
    I shall learn your commands to obey.

  You loved me before I could tell
    Who it was that so tenderly smiled;
  But now that I know it so well,
    I  should be a dutiful child.

  I am sorry that ever I should
    Be naughty and give you a pain;
  I hope I shall learn to be good,
    And so never grieve you again.

  But, for fear that I should dare
    From all your commands to depart,
  Whenever I'm saying my prayer
    I'll ask for a dutiful heart.

I suppose this says a lot about the way that children were looked upon 200 years ago.  There's a lot about it that makes me uncomfortable.

November 22, 2009

Milk 2

In most of the First World, people have enough sense to appreciate the disease-prevention aspects of modern hygiene.  In most of the third world, parents sacrifice in ways we can’t imagine to get a hold of basic survival needs of their children, like clean water and pasteurized milk.

When I lived in Utah, I met people who actually believed that treatment of municipal water was, in fact, some sort of technique by which our government was trying to control its noncompliant population.  Before I moved to Utah, I thought this was a creative device sprung fully-formed from the creative genius of Stanley Kubrick and Peter George, who wrote Dr. Strangelove.  I thought I had been transported to a scene from this classic cold-war movie, in the early 1960’s.  Now that I think about it, there were a lot of things about Utah that made me feel that way.

I was asked to write a letter saying that there was a medical reason that a preschooler should not be compelled to drink raw milk.  And, in this case, raw cow colostrum.  Apparently, the raw milk just wasn’t raw enough.  Though I’ve been here in Berkeley for more than a decade, I had never heard of people drinking raw milk or giving it purposely to their children.  So I don’t know how relevant these two posts on the topic will be for normal people who live in normal places and make normal decisions.

A comment came to the previous post inquiring about the accusation that pasteurization kills the good bacteria along with the bad in milk, and doesn’t that leave us without an important source of crucial digestive flora?  I thought about how to answer this question, besides the obvious fact that very few kids drink raw milk, lots—thousands of times as many—kids drink pasteurized milk, and all those kids don’t have serious problems with their digestive ecosystems.  But I have another way to look at it.

It’s hard to study babies.  Most parents don’t want scientists messing around with their babies, and I’m not sure it’s ethical to be poking and hurting babies for the fulfillment of scientific curiosity.  But there’s one kind of study that usually flies through every committee and review board designed to protect patients from the voracious appetites of modern science.  The poop study.  Baby poop is plentiful, easily collected, doesn’t hurt the baby and is a more renewable resource than the greenest, fair-tradiest most organic product available.  When the supply in the lab runs low, it’s not that difficult to find more.  Just about everything about this miracle material that can be studied has been studied.

Meconium, the black tarry stuff that emerges shortly after the baby emerges, is sterile.  It’s what remains of the cells that have developed into the hoses and culverts of the baby’s digestive system.  Within 48 hours of birth, every gram of the fresh stuff (every 1/30th of an ounce) has about 1,000,000,000 bacteria.  Can you imagine how crowded it is down there after a year?  Yet, somehow, all of this population explosion happens without a drop of cow’s milk, raw or otherwise.  So how essential is it?

I was told that the good bacteria in raw milk act to fight off the bad bacteria, so pasteurization actually increases the risk of getting bad bacteria.  It was hard to understand this.  But it shows a serious weakness in critical thinking.  Let’s say that it works just like they say:  good bacteria keep the counts of disease-causing bacteria relatively low.  So how is this more effective than giving your kids the kind of milk with no bacteria?  How is hoping—assuming—that the dose of deadly infectious bacteria in the raw milk you’re serving won’t be high enough to kill your child better than giving your kid the kind of milk with no bacteria?  And what about the argument that if the cow is not a feedlot cow, and is raised in a relatively pristine environment, that raw milk can be the cleanest milk available?  A few such careful families decided to pool their resources and together buy a diary cow on a farm in Washington.  In 2005, after 4 cases of potentially lethal O157:H7 E. coli were found, an investigation found a total of 18 cases.  157 people were interviewed in the investigation, but nobody became ill who didn’t drink raw milk.  17 of the 18 affected people were either part of the cow-share or children of those families.  One child was a friend who had visited and was given raw milk.  Though the age range of those affected was 1-47 years old, the median age was 9.  All of the people hospitalized were 1-13 years old.  It’s not hard to figure out why.  Of those who drank 0-1 cup of milk a day, 4% got sick.  1-2 cups a day, 7% got sick.  Of those drinking 3 cups a day, 38% got sick.  Four people in this group got Hemolytic Uremic Syndrome, in which the kidneys shut down.  It’s not something you want your child to get.

In Pennsylvania in 2007, it was Salmonella Typhimurium from raw milk at a farm stand.  Sure, most people merely get extremely ill from it.  But the case-fatality rate (yes, that’s what it means) can be 5-10% in newborns or the elderly.

What if the raw milk is “certified?”  It was easy to find reports of infection from this unregulated definition.  In an outbreak in Germany, consumption of raw milk was the only food risk factor for children under 3.

And what about lactose intolerance?  Since both pasteurized and unpasteurized milk contains lactose, there’s no advantage there.  The enzyme needed to digest it, lactase, is more active in some people than others.  For the lactose-intolerant, who have low levels of lactase, drinking raw milk (which has just as much lactose as pasteurized milk) is not likely to be an improvement.

Giving young children raw milk is dangerous.  There are lots of websites with all kinds of testimonials to its benefits.  I looked for studies confirming some or any of the alleged benefits of drinking it, and found only reports of disease and death.

 The next time somebody suggests you give your child raw milk, ask them why, and then ask how they really know that it does what they claim. 

The magnificent photograph at top is by the late Harold Edgerton, a professor at MIT and inventor of the strobe light.  He discovered ways the world worked that we never had any idea about.

November 16, 2009


This week, once again, I have had the privilege of performing a duty only those of us working in the rarefied atmosphere of Berkeley California (and places like it) get to do.  I had to write a note to a preschool principal requesting—insisting, actually—that one of my patients be served only pasteurized milk.

glass of milkRemember the wax paper containers that we had in elementary school?  It was never clear which side you should open, though it did seem that one side opened easier than the other.  Often enough, for inexplicable reasons, both sides got open and the container, now missing apparently key elements of its structural architecture, would become floppy.  Drinking from it became difficult.  I’m not, just so it’s clear, nostalgic for those little containers.

To most stories, there probably are at least two sides.  The great leaders of history weren’t always the nicest people.  Certainly, along the way, history must have gotten a few of the details wrong, with the result that some of the people we admire were probably not so admirable in real life.  Here’s the thing with really big hit movies, too.  Maybe they didn’t sound so appealing when they were first released.  Maybe you weren’t so impressed when you first saw the movie.  But when not just a few but people from all over the world are seeing the movie and loving it, again and again, it must have something appealing.  So the next time you look through a list of the top 100 movies of all time, maybe you should take a chance and rent the ones you haven’t seen.  I don’t believe that the public at large is usually right about things.  But when great works of art, great people and their discoveries, stand up to the rigorous tests of time and repeated scrutiny, there’s probably a reason.

I’m willing to cut Louis Pasteur some slack.  He’s got a really famous institute named after him, and his tomb is mighty fancy.pasteur grave   That’s not enough.  In the last quarter of the 19th century, New Yorker Jacob Riis wrote about baby ‘farms’ in which some poor adults would, for money, take in babies from families who couldn’t afford to care for them.  The milk they were given wasn’t good, and these caretakers would give them opium to keep them quiet until they died.  This freed up space to take in more babies.  None of this particularly attracted attention, both  because of the poverty of the families involved and the brutal routine nature of this kind of illness.  This was chronicled in How the Other Half Lives, which Riis published in 1890.  In 1891 the infant mortality rate in New York City was 240 per 1000 births.  That’s about 1 in 4.  After a lot of controversy and debate, and after a major typhus epidemic blamed on raw milk, New York started enforcing rules about pasteurization.  Within a few years, the mortality rate for infants had dropped to 71 per 1000, 1 in 14.
The bacterium E. coli is in all of us.  It’s a normal component of our digestive system.  One subspecies of E. coli that has turned to the dark side is called O157:H7.  It’s a bad thing to get, and can make people very sick.  It can kill you.

cowsDuring a 20-year period, from 1982-2002, about 4% of all O157:H7 cases were from raw milk products and colostrum.   Think about that.  It’s hard to get raw milk in most places.  Much, much less than 4% of the population eats raw milk products.  That means that those who do have a very high risk, compared with the population as a whole, of getting this potentially deadly infection.  Do I need to say that children are particularly vulnerable?
The first time I saw a case of Hemolytic Uremic Syndrome [HUS] I was in training and working in a children’s hospital.  It’s not something you would have seen outside of an intensive care unit.  The 4-year old I watched over was on dialysis and waiting for a kidney transplant.  She got O157:H7, was sick for no more than a couple of days before her kidneys shut down.  Even with the dialysis, without her kidneys working her body found it hard to regulate important functions like blood pressure.  There was no happy ending.

I know this is a pretty dark way to come back to the blog after a week and a half or so.  But this isn’t about disease, infection, Louis Pasteur, poverty, or organic produce.  It’s about parenting.

I believe that every caring parent has the best interests of their child at heart.  But parenting requires the use of a brain, as well.

I asked the parents who requested the letter from me to ask the people at the school why, exactly, it was so important for every child to have raw milk.  They called me and said that they were told it was simply better for the child and that there were a lot of health benefits.  ‘Like what?’ they asked.  Better nutrition they were told.  ‘Really?  More vitamins or what?’  But that was as much as they could get.  This very superficial scratching of the surface of belief revealed a hollow center.

Ask me why your child shouldn’t have raw milk and I’ll tell you what I know, what I’ve seen with my own eyes, what I’ve read a dozen times from independent sources and studies all over the world—it can be lethal.  Now ask that nice person in the mom’s group why it’s worth risking your child’s life.  What precisely are the benefits that are so overwhelming to make up for that?

November 4, 2009

Swine Flu Update November 4 2009

Sometimes our government does things really right.  I think the Centers for Disease Control [CDC], year in and year out, does a great job.  And they do it for the whole world.  (At least for them, for free.)  Before any of my patients go to exotic locales, or sometimes not so exotic ones, I will check their website for up-to-the-minute news of outbreaks or cautions.  Their very best feature is a real-time Traveler's Health section, where you can find what's going on disease-wise in any place on Earth, and if your next vacation leaves you exposed to Chikungunya Fever.

Feeling this way, from years of experience, has left me particularly confused about the current H1N1 vaccine situation.  I heard from our government just months ago that there would be available 130,000,000 doses of vaccine available.  They did a fine job of publicizing the epidemic, so that many of those who never got flu vaccine before are now asking for it. 

I have a long list of children whose parents want them to get the vaccine, and many of those children have complicating risk factors.  I haven't received even 1 dose so far.  In this area, Kaiser Permanente (presumably the largest organization ordering vaccine) got theirs a couple of weeks ago.  Some other counties have had it for a while, too.  Larger medical practices are getting deliveries.  Not me, not the small practices.  When--if--I get some in my office, will it be like the seasonal flu vaccine?  I ordered it last year, received a fraction of what I ordered, and can't get more.  There is no more, and many of my patients have had to do without. 

One of the things that's so confusing is the number of doses available.  In the 3 or 4 months since the 130 million number was being mentioned to every news outlet, a large proportion of those doses failed to materialize.  I've tried to find an authoritative link on this, but haven't been able to.  A lot of sources suggest 14 million, some say a little more than that, but much will only be available in 2010.  The CDC website says that as of October 30, 2009 16,870,000 doses have been shipped.  Where did it all go?  The manufacturing cycle for vaccines is a long one.  Batches are grown, purified, prepared.  If things were going slower than expected, were they going 90% slower?  How come the government didn't know or didn't publicize that or tell us what to do instead?  Are there manufacturing plants that have broken down?  Labor unrest?  All the reasons I can think of should have been known and followed intimately by the same people and institutions that seem to have been so vigilant (and generally right, by the way) about the upcoming, now ongoing, epidemic.

I'm faced with a problem.  If I don't get enough, who do I give it to?  I know who the most vulnerable patients are, and I will be ranking them.  It's not a list you want your kid to be on top of.  But it's a list you still might want your kid to be on.  Why do I have to make this kind of choice? 

I need to point out that I am not blaming anybody for this situation.  If it were possible to deliver all the promised doses, I'm confident it would be done.  But I do feel that we all should have known long before this.  The lack of information could have serious health effects.  Next year, there will be studies of the cost of the H1N1 epidemic.  The cost of treatment, hospitalization, interventions of all kind, doctor and ER visits will be added to lost wages and time spent staying home with the sick child.  But what won't be counted is how much might have been saved--even without the vaccine--if we had been able to plan a little better with better, more timely information.

With all the above said, here's some information available this morning, as a service to my patients and their families, and to the many readers of this blog everywhere.

Questions and Answers about the H1N1 vaccine.
Is it safe?
A guide to antiviral drugs for the flu.

What to do if you or somebody close to you gets the flu.
Pregnant women and this flu.
State of California Public Health link.
City of Berkeley flu link.
FAQ for parents about H1N1

For kids, adults, and probably free:
Alameda County H1N1 vaccine clinics.
Contra Costa County H1N1 vaccine clinics.