October 11, 2009

The Human Pacifier, Part 1

When Andy was 4 months old, his parents brought him to me and asked why he wasn't sleeping through the night. It was our first visit, and they had heard of me and chosen me carefully. They had not been satisfied with their original doctor, and drove about 90 minutes to see me.

They said that he was constantly hungry, and demanded to be fed every hour through the night. Mom was anchored to the co-sleeper, which enabled her to get what little rest she could. At least with this arrangement, when the baby awoke, she could give him a quick feed without getting out of bed, and then both could get back to sleep. Dad was now sleeping in the other room, because he couldn't function at work after being awakened every hour.

Insatiable hunger can be a sign of a serious medical problem. As you can imagine, however, the desire to eat nonstop usually appears in those who look one of two ways. The obvious one is very fat, since if you're eating much more calories than you expend, your body stores it up (welcome to my world). If, on the other hand, there's some innate—presumably pathological—drive within you to eat and eat, but it's because your body isn't absorbing the nutrients it needs and therefore isn't sending your brain the signal that you're full, it's possible to be insatiably hungry and yet be starving. There are many malabsorption syndromes and diseases like this. Perhaps the most common is Cystic Fibrosis, which causes the pancreas to fail in the production of key enzymes and factors that help us absorb and digest different nutrients and fats. If you don't absorb fats, you miss out on a lot of calories. All of this is simply to say that I take seriously the observation that a child is insatiably hungry.

Note that if your child were insatiably thirsty, get your kid to a doctor right away.

But there's a reason we do growth charts. The happy baby smiling and laughing with me was at the 50th percentile for weight, height, and head circumference. He wasn't thin or fat. He was exclusively breast fed. Though it's possible to overfeed a baby who's breastfed, it's a lot more common in bottle-fed babies whose parents, for whatever reason, use the bottle to soothe the baby. Since a baby sucks for comfort (they are often seen on ultrasound sucking on their own hands or fingers in the womb) and sucks instinctively (they will suck on a stick or anything placed in or near their mouths), these parents get the mistaken impression that if the baby is sucking on the bottle, the baby must have been hungry. Andy had not been overfed.

Though many people wait until 6 months to start solids, and I generally recommend that too, this was an exception. I thought that if we started solids right away, at 4 months, it might help. Solids of all kinds generally move through the digestive tract much slower than liquids. And much, much slower than breast milk, which is very easy for the baby to digest. My thinking was that if the solid feeding were at night, the baby might stay full a lot longer, and thus not awaken hungry so often. Great idea, I was assured by the parents, and they would try it.

It didn't work. A month later, they had driven all the way to my office for follow up. Not from the drive alone, they both looked exhausted. The baby was 5 months old and awakening every hour. He did great with the solids, still rice cereal, once a day. He continued to be at the 50th percentile for growth. I had to take a better history.

Mom said that he nursed like a champ during the day. He spit up a little but not too much. He liked the cereal they had tried. He didn't mind being put down into the swing or the car seat, but hated being put down flat. Andy had taken to shaking his head vigorously against the crib mattress when he was put down, and now he had a little red area there that they think was caused by this.

I asked about the specifics of this 'insatiable hunger' that mother described. She said that almost like clockwork, he would wake up every hour during the night and make some noises—not crying exactly, but she said that she knew that if she didn't nurse him right then, he would escalate this into a vigorous cry and it would be much more difficult to get him back to sleep. So she now hears these little noises, and wakes herself up, picks up the baby, nurses him, and he goes right back to sleep. This process repeats every hour through the night.

Each feeding lasts, she said in response to my asking, about 1-3 minutes. She doesn't change him, because that, too, would wake him up more and make it tougher to get him back to sleep. How much, I asked her, did she think he was really getting during those feedings. “Not much,” she admitted. “I feel like a human pacifier.”

The situation in brief:
  1. Baby won't sleep solid 2-6 hours at 5 months;
  2. Mother not getting a sustainable amount of sleep;
  3. Father sleeping in another room.
Are the following facts related:
  1. The baby is insatiably hungry, but is growing normally;
  2. The baby hates being horizontal, but is OK in the swing or carseat;
  3. The baby shakes his head on the crib mattress;
  4. The baby nurses a lot during the day.
And lastly, what exactly is my job and how do I perceive my role in this family's life? Here are some choices:

  • The baby is growing and developing normally, so I can reassure the parents that they will all get through this difficult time and that they should return in 2 months for the next scheduled well-baby visit. (This, by the way, is the 'standard of care.')
  • I should try to diagnose the reason for the baby's frequent awakenings, and treat this or at least help the parents understand this.
  • I should avoid 'medicalizing' this normal variant of infant behavior and development. I shouldn't agree with the parents that the baby has a problem. It's their problem having difficulty living in their otherwise-normal baby's life. Why does every minor inconvenience need medical intervention? Does this require a diagnosis?
  • Is the baby suffering? After all, he's my patient. If the baby—laughing and smiling with me in the office—is none the worse for wear, everything else is incidental to me as his physician.
  • Do I try and fix this? In the early 19th century, a popular medicine for babies was Godfrey's Cordial, a liquid mixture of molasses, sassafras, and opium (sometimes brandy). The good news is that it worked great. The bad news.... If I decide to try and fix this, what exactly do I fix? What's broken? What, when all is said and done, is my job?

Next post: My analysis and decision process at the end of the visit.

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Please let me know what you think. Do you know a child or situation like this?