October 15, 2009

The Human Pacifier, Part 2

I've said it before in this blog, my job is to make lives better. To relieve suffering, if I can. Often, this includes making a diagnosis with the appropriate treatment flowing consequentially from there. In her Diagnosis column a couple of weeks ago (based on one of my cases), Dr. Lisa Sanders makes the observation that we often will never know if the diagnosis was right, “...only if it was right enough.” And sometimes making a diagnosis has absolutely no impact on the patient's life. So diagnosis isn't my job. Heaven knows that curing disease isn't my job, since that's only possible occasionally.

In my previous post, The Human Pacifier Part 1, I tried to deconstruct the issues as I saw them at the end of a 2-hour visit with the parents and 5-month old baby, Andy. He was happy and playful with me, but up every hour at night. The result was a severely sleep-deprived mother and a marriage that wasn't sustainable in the current situation.

I made my choices of how to approach the problem based on how I see my role, by my experience, and by who I am and the kind of doctor I want to be. In my career, I have worked with many other doctors and I know what most of them and all of the insurance companies would have me do:
  • The baby is my patient.
  • The baby is OK, healthy and developing normally.
  • Establish the health status of the baby, give the parents a handout (called, perhaps ironically, 'anticipatory guidance') and make an appointment for the next well-baby visit.

Total time of visit: some places 10 minutes, some 15-20 minutes.

My visit: 124 minutes. What was I doing? Mostly, I was listening to the mother and father. Here's what I learned from listening, that others might have missed.
  1. The baby would shake his head violently when placed on the crib. No, that's not normal. A very careful exam of the child's head showed a pink, flaky area on the back of the baby's head. Cradle cap? Ringworm? (The baby's awful young for ringworm.) In the course of the long visit, while talking to the parents, I was making faces at the baby and watching his response. Smiling. Laughing. Scratching. Sure enough, the baby was sometimes scratching his head, his thighs, his stomach—pretty much wherever he could reach. So I didn't just look in his ears and listen to his heart. I gently ran my hands over his skin, and the sandpaper-like patches were obvious to the touch, but invisible to the eye. I don't know if the little patch on his head was pink because of the head thrashing, but I knew the baby had eczema. Studies clearly show that babies who are itchy (and adults too, by the way) don't sleep well. They don't sleep as deeply and awaken more easily and more often.

  2. The baby didn't like to be horizontal. He didn't spit up much more than usual, but he was spitting up after nearly every feeding. He seemed to sleep better when propped up in the swing, even if the swing wasn't going. Though every baby is born with gastroesophageal reflux, some of them show remarkable and rapid improvement in their irritability, sleep patterns, and willingness to be placed on their backs following basic anti-reflux positioning and medications.

  3. In the Pavlovian world of conditioning, who got to play Pavlov's Dog—the baby or the mother? Here' my interpretation of what was happening in the bedroom, where mother slept in the bed attached to the co-sleeper where the baby slept, while dad slept in the other room. As in the analysis of any two-part system, let's look at each component.

      1. The baby. Have you ever slept in a place (maybe grandma's house, maybe sleeping over at a friend's house) where somebody woke up early to bake fresh muffins in the morning? OK, maybe it was bacon frying in the morning before you were up. I'll come back to this in a moment. First, my view on the baby's sleep. Here's what happens. We cycle through various stages of sleep. In stage 1 sleep, we're just barely asleep; in stage 4, we are not moving, breathing slow and deep. In Rapid Eye Movement [REM] sleep, we talk in our sleep, move around a lot, and dream. I suspect that in the baby's REM sleep stage, he's vocalizing just as he did with me in the office. It's not crying, just making vocal sounds. In this stage of sleep, he's also moving around. Whether he's dreaming of breasts is anybody's guess. But he makes some sound, that mother is pre-emptively reacting to. Even if this is just a stage of sleep from which he will descend without help into a deeper and quieter stage. But mother picks him up and...fresh muffins! Now, not only does he have an incentive to jump out of bed and check out whatever delicious goings-on are happening in the kitchen, he is rewarded for doing so by the positive feedback of mother's touch and nursing.

      2. The mother. Anyone who's ever used an alarm clock to get them up for school or work knows that the alarm clock makes itself superfluous. For a few days, maybe a few weeks, on the same schedule, the alarm clock wakes us up. Sometimes groggy, we force ourselves out of bed and off to work. Even if we go to sleep way too late the night before, we still wake up moments before the alarm goes off. What's happening is that our brains have been conditioned in ways that I don't think are fully understood. Somehow we are programmed to awaken at a certain time every day. For new parents, they—or sometimes just mom—get so sensitized to the sounds from the baby or baby monitor that they hear these sounds even in a crowd or over the sound of a TV. The baby is smelling fresh muffins when he's not awake, but in a shallow-enough sleep stage to pull himself to wakefulness. Mom has been conditioned to anticipate the alarm before it goes off, and never lets herself get to a deep enough sleep stage for effective rest. She is also conditioned to awaken at the first sounds that come from the baby, whether or not they are a request for her services.

      3. The pair. This coupled system could, in a previous life, have induced me to attempt to model and analyze it. Suffice it to say that the baby does what comes naturally, with a spiral of positive feedback. The mother does what comes naturally, from the love for her baby and the willingness to sacrifice. But it's a dysfunctional system, in which the unsustainability of prolonged sleep deprivation of the mother will not have good or even benign consequences for the baby. Aha! The baby is my patient.

    1. The problem of mother's lack-of-sleep, and dad sleeping in the other room, is a problem for the baby and needs to be fixed, if possible.

    2. What difference would a diagnosis make? The baby was not in medical danger from some unidentified disease. I just needed to get this mom through the night.

A diagnostic algorithm for this baby would require sequential interventions or perhaps tests of various kind. These would be done in series, so that the effects of each intervention could be assessed. I thought the baby had eczema, and I knew that itchy babies didn't sleep deeply. So it would be reasonable to use some cream that could relieve the itch and see if that solved the problem. We could give it a couple of weeks and if it didn't work by then, we could do some tests or try some antacid medication for what seemed like heartburn in the baby. If that didn't help in a couple of weeks, we could change the feeding pattern of the baby. Maybe some more solids would keep the baby full longer and put him to sleep more easily. If that didn't work in a couple of weeks, we could try a different sleeping arrangement, and a couple of weeks after that, we could change what mom was doing. Eventually, we might try something and then the baby would sleep through the night. Then, we'd know what the problem was. Of course, by that time the child will be off to college and the mother will be heavily medicated.

Next post:  What I did, what I told the parents to do.

The poster at top is in my office.  It's from the Tony Nourmand collection originally, and is published in Exploitation Poster Art (Aurum Press 2005), page 170.  It's from 1934 and was about parents whose behavior made them guilty.  I like it for the irony of 75 years later:  not parents being guilty, but parents feeling guilty.

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