August 20, 2010

Hothouse, Part 3

My strategy was simple but subtle. I was there in Amy's house, sitting at the foot of her bed in the sauna-like bedroom. I was worried about her, and I needed to help. I wanted to uncover each concern, shine daylight on the dark corners where the unknown and the irrationally-feared thrive.

So I reviewed the baby’s weight history (normal) and recent weight gain (great). The baby wasn’t getting nutrition, not even fluid, from any other source. So that must mean that Amy’s breasts are doing a great and normal job at keeping him healthy and thriving. There’s no evidence of any kind that her body will either suddenly or gradually stop providing the milk it has already proven that it can provide. She understood the logic, but didn’t have a lot of confidence for the future. She asked what would happen if, despite her excellent track record, she just failed to make enough or any.

What indeed, I asked her back. I guided her through this unlikely scenario the way we should plan a fire exit in our homes. First, would she know? She didn’t have confidence that she would, so I asked her how she would find out. She correctly figured that the baby would be hungry. Since her baby was neurologically normal, and since hunger is one of our most primitive and basic drives, the baby would surely let her know if he weren’t getting enough.

She wasn’t debating with me, but my answers gave her the freedom to ask the frightening questions without being judged harshly. What if the baby was crying and she couldn’t tell if it was from hunger and it really was but she didn’t know? OK, how long would you let the baby cry before calling me? She didn’t know exactly, but it was a lot less than a day. She agreed that her healthy baby could go a few hours without eating and still do well. If the baby really were crying inconsolably, I would always want to be called and usually want to see the baby in person. This is all pretty standard stuff, I think. As we went back and forth on this precise topic, however, I happened upon the answer she needed. I hadn’t understood exactly what would break through this until I hit upon it after trying other answers. 3 hours. That was the key, as it turned out. She was glad to get the reassurance, glad to get my commitment to be there if needed, confident in my professional skills and judgment. What she didn’t have was the confidence to trust her own common sense and innate ability to see when the baby has crossed over from fussy to worrisome. She needed an unambiguous border she could look for. If the baby crosses it, she knows exactly what to do. I could see the relief on her face when I said 3 hours. Any time, day or night, for any reason. Hunger, illness, bad weather, it just didn’t matter. If you try everything you know and the baby is crying for 3 hours, call me.

That wasn’t the only breakthrough. Like many new mothers I see, she was anxious about her continued ability to nurse successfully, even though she had been doing it perfectly. There are sometimes reasons that women have to stop, but they aren’t common. Usually, with some support and expert advice, breastfeeding problems can be overcome. But how, she wondered, does she really know that? She has already taken her body places it has never gone. Sure, my experience is optimistic, but that’s based on other women, other babies. This, I admitted, was an excellent point. I don’t push formula, but this is its perfect role. How do we know if 911 will answer when we call? Still, we teach even kids this number. That can of formula can usually sit on the shelf of a kitchen cabinet for a year. It can wait like a silent guardian, hidden behind the stuff you actually use. Nobody but you and your doctor need to know it was ever there. A can might feed a baby for several days or a week, depending on how big they are. But even if never touched until you throw it away when discovering it as you pack up to move, it is working its magic as an effective contingency plan. Depending on the disfavor in which formula is held, it might not be plan B or even C. But the one day when you decide to leave the baby with your mom for a few hours, but a truck got stuck under an overpass and there’s no way to get off the freeway and people are stopped and getting out of their cars, that can will be there.

Next, and I’ve made this point about bicycle helmets, protecting the baby might be a necessity but the safe and thriving baby is nowhere good without you. So taking care of yourself is crucial for the baby’s life and happiness. mavericksNo, that doesn’t mean I think you should give in to the urge, ever since you heard of that big storm in the Gulf of Alaska, to have a neoprene Snugli custom made so that you'll be prepared when you get the text that Mavericks is up—way up—and you want to show the world how gnarly you really can be. Once the baby’s needs are met, we need to find a way to fold them into our  lives in some functional way, or perhaps fold our lives into theirs. For Amy, this meant getting out of bed, out of the sweatpants and into regular attire and footwear. Another subtle advantage of housecalls, I made this suggestion to help her, not hurt her feelings. Perhaps doctors don't usually make fashion tips, but this was an essential precursor to the final note of this post.

This last is important because it facilitates the next important suggestion I made. She needed to take a walk. I strongly urged her to go for a walk with the baby in a stroller every day, without exception. Every part of this idea has a reason behind it. The feedback I've received has been so consistently good about it that it seems inexplicable for it never being mentioned in my training or textbooks.

The walk allows the new mother to get some exercise. Since this is often after spending at least a few days in bed, even previously fit mothers should take it easy at first. And for goodness sake, check with your OB who may have information about your stitches that I just don't. Studies have clearly shown that even a couple of days in bed decrease our fitness level. Together with some blood loss, you need to get back on your feet. Studies have also consistently shown that exercise improves our mood. People who get some exercise every day tend to sleep better, and some important functions of their body seem to work better. These include breathing and digestion.

The walk allows the mother to get some daylight. Amy hadn't left her bedroom much since leaving the hospital. Her planning for the baby had been so good, in fact, that her room had a changing table and baby supplies, a crib, swing, and so on. I noted this as her mood gradually lifted, and inquired when she planned to start using empty tissue boxes as slippers as Howard Hughes apparently did when he sealed himself in the penthouse of a casino he owned. Just because she was suffering didn't mean I couldn't make fun of her. Daylight, too, has been demonstrated to lift the mood and help regulate sleep.

Daylight is also helpful for the baby. It is directly therapeutic for jaundice, which baby Henry didn't have. But the baby had been living in a dark cave for 9 months. It needs daylight exposure (not direct sun, just daylight) to establish a day/night pattern. It also needs daylight to help provide vitamin D, which is activated by sunlight.

I specified using a stroller for several reasons. The jostling of the stroller is a natural pacifier, which many babies find soothing. Slings of many kinds can be great when doing many activities, especially in places with a lot of other people around, such as supermarkets. But the stroller takes the weight off. There's no extra weight on your back, no extra weight on your hips and knees and ankles. That will make the walk just a little easier, and make you able to walk a little bit longer than you might be able to with a sling or backpack carrier. It also gives you the luxury of stopping. If the baby's asleep, you could stop at a park bench. The stroller also moves the baby away from your body. This seems counterintuitive, since I certainly want you to hold and love your baby pretty much constantly. But it brings up the timing issue.

Take the daily walk at the baby's fussiest time. If your baby is consistently fussy in the late afternoon, say between 4:00 and 7:00PM, that's the time to go out. There aren't too many things more frustrating than trying and failing to comfort a fussy baby. It makes us feel helpless and doubt our ability to parent. But if the baby's basic needs are being met, and we know he'll be fussy in the late afternoon, that's the time he'll benefit from the calming effect of that walk in the stroller. If it's his fussiest time, he won't be right in your face, reminding you of your shortcomings as a parent. That, after all, is what adolescence is for.

August 17, 2010

Hothouse, Postpartum—Part 2

hothouse_web Like every new mother, or maybe at least the good ones, Amy said she was worried if her baby was getting enough.  Henry was a week old, and I walked her through my iterative procedure to determine if he was getting what he needed.  He was gaining weight appropriately.  He was having lots of wet diapers.  He was satisfied after nursing, and could be heard swallowing voraciously at every feeding.  This was apparently an adequate response until she asked me if I thought he’d be alive in 6 months.

I wasn’t going even to try and finesse this over the phone.  I stopped at the supermarket, picked up a small portion of hot macaroni and cheese along with a little bit of cut-up watermelon, and drove directly to her house.  Intentionally, I did not ask if it was a convenient time for a visit.  I didn’t care if it was convenient—it was necessary.

Her mother was there to open the door.  Though it was just a few minutes ago when we were on the phone, her mother had arrived in the meantime.  I thought that was lucky and we introduced ourselves.  I asked where Amy was, and her mother directed me upstairs.  I was carrying the old-fashioned  housecall bag that I kept in the car, but I didn’t think I would need to examine the baby. 

Henry was a term baby, and healthy.  Amy had been doing a good job keeping up with the demands of initiating breastfeeding, and her general concerns were common, reasonable, and could be comfortably answered with rational reassurance.  

I walked up the stairs to the master bedroom, where Amy was in bed, holding the baby.  It’s was a nice big room, with big windows that looked out onto a garden.  The windows were closed.  I asked how she was and she said she was OK.  The baby was OK, too.  It was nice of me to come over, but it wasn’t really necessary.  I told her that I had brought over a little watermelon, which has a lot of water in it.  It was July, after all.  I also brought over some macaroni and cheese—though I had this before and the store where I bought it usually makes it quite bland.  It was a good way to raise your blood sugar if you haven’t been eating right.

She admitted that she hadn’t really been eating right.  She was in bed, I noted, and it was about 5:30 in the afternoon.  She said she hadn’t been out of bed much, either.  I didn’t mention it, but I didn’t really understand why her mother was downstairs and she and the baby were upstairs.  It’s hard to know what the right approach is to get a channel of communication open.  I’m usually very good and very intuitive at this with children, but I’m not as skilled with adults.  I decided that for the moment, I’d let my actions speak for themselves:  I was there.  I didn’t tell her to call if something happened, I actually showed up.  I believe that sometimes that is exactly what’s needed.

So I didn’t immediately confront her about what she said.  “Do you think it’s warm in here?” I asked.  It felt like a sauna to me, though I’m biased by my weight.  I was self-conscious about the beads of sweat I knew were appearing on my bald scalp.  In my little doctor bag, there was an infrared thermometer.  It read 95° [35°C].

Amy said, “Oh god yes.  I like it cool and so does my husband.  But it has to be warm for the baby, right?”  

Is the baby cold?” I asked.  He looked comfortable enough in her arms, wrapped in a blanket and wearing a hat.  

How can I tell?” she asked.  I asked if the baby’s hands or feet were cool or purple.  She had to unwrap him to look, and they weren’t.  But, she noticed, his back was sweaty.  I put down the doctor bag.  I asked if it had been this temperature in the room for the 4 days since the baby was brought home from the hospital.  It had been, she said, because they wanted it to be comfortable for the baby.

I walked to the windows and opened them.  “What are you doing?” she asked.  

“I’m making the room temperature compatible with life for non-reptiles.”  I explained that if having a newborn baby in the room was not enough of a cause of sleep deprivation, being uncomfortable would suffice as well.  

Her thought was reasonable, even right in a way.  Babies do have more difficulty maintaining their body temperature and need to be kept warm enough, especially if undressed.  But they are warm-blooded, at least in some general Linnaean sense.  They will maintain their body temperature with appropriate energy resources and insulation.  I coached her on this point as I undressed the baby and took off his hat.  I suggested a couple of thin layers, that were easy to add or remove as needed.  That kind of management is less practical for adults, so it was important to keep the environment comfortable for her and her husband.  The baby could be dressed as needed.  She liked this idea.

Maybe to my sophisticated readers this will seem simplistic, but I don’t think it is.  Again and again I find that housecalls can be profoundly helpful, often in unexpected ways.  In this case, Amy did indeed have some postpartum depression.  We are dealing with that, hopefully, in helpful ways.  But the housecall accomplished several important things.

She knows, in a convincing way, that I will actually come to her house if needed.  She’s not in this by herself.
I know what she’s got, I’m concerned about it but not frightened away.

She has my permission to be comfortable.  This is so important.  It’s crucial, of course, that the baby gets what he needs to thrive.  But those needs are pretty basic.  Once the baby’s needs are met, the next priority is finding a way to make the new world order work for the parents in some practical way.  Amy was doing a good job with the needs of the baby.  She was ignoring her own.  I wanted her to know that getting some relief in the misery of the mother is good for the baby, too.

After making the ambient temperature low enough to assuage my concern that the buttons on my shirt might melt and leave permanent scars seared into my chest, I had several other suggestions for her.  That’s next.

August 14, 2010

Hothouse, Postpartum—Part 1

hot-house-book I arrived at Amy’s house just a few minutes after hanging up the phone.  I brought my house-call bag with me out of the car, but I didn’t think I would need much to examine Henry, who was about a week old.  He had been full-term, and was doing everything right.

Before the baby, Amy was a working professional, very smart and with a good sense of humor.  This is often an important coping skill.  It can also be an important tool for parents who bring their children to me.  I often have to remind them that:  ‘Just because you are sick or in pain doesn’t mean I can’t make fun of you.’  It’s a coping mechanism for me too, of course.  I try to help parents see the humor or absurdity in themselves and what their kids do.  But, I suppose like all humor, it doesn’t play to every audience.  The families who appreciate my point of view know that when needed I can slip quickly into the role of a serious doctor.  Sometimes it’s hard for me to tell what’s needed.  Being happy is often infectious, so staying upbeat can bring somebody up.  But being unrealistically optimistic can make a depressed person doubt your sincerity and simply not trust that you understand how they are seeing the world.

The phone conversation with Amy started in a typical way.  She had some concerns about breastfeeding, especially wondering if the baby was getting enough.  This was the most common question that new mothers asked, and I explained that we can be reassured if the baby is gaining weight and having lots of wet diapers.  If he’s growing and peeing, and not sneaking out for snacks when she’s not watching, he must be getting it from her.  That was the ‘gold-standard’ for determining breastfeeding success.  She bought that reasoning. 

But when she asked the real question, which she tried to hide in the words of an innocent question, alarms developed over my years of experience started ringing.  She asked if I thought she’d still be breastfeeding in 6 months.  And added, quietly, “if he’s still…here.”

Though nobody wants to bring it up, every parent has dark fears.  I think we all do about people we love and depend upon.  The inconceivable loss looms, we all know, above us too distant to see clearly.  But we know it’s always there, hidden in tragic news stories that happen to other people.  We’d all be in trouble, however, if we fixated on this instead of going about our daily tasks.  A couple came to interview me to see if they wanted me as their doctor.  They had just moved from Florida with their baby, and I was making pleasant conversation.  I asked why they moved.  They said they had stayed through a couple of hurricanes last year.  That was enough, they said.  They had a child now, so they moved here to the Bay Area so they didn’t have to cope with the constant threat of a natural disaster. I told them I would be happy to have them in my practice.

The dark thoughts are there, lurking deep in the background.  We might know how fragile babies are, but good parents shove these concerns to a back burner while they focus on feeding the kid and making sure they don’t run out of diapers. 

It’s natural to wonder if the baby is getting enough.  It’s natural, even, to worry about it.  If the baby isn’t getting enough, he might not gain weight well.  He might even lose weight.  He might—heaven forfend—have to get formula.  Most parents who have these concerns are genuinely worried.  They might or might not realize that these concerns are sometimes out of proportion to the actual risk to the baby.

I tell parents that they should never tell a child who’s getting a shot that it won’t hurt.  Shots do hurt, at least a little.  A smart child will immediately reach the correct conclusion that either you didn’t know that shots hurt or that you knew and lied about it.  Either way, you’ve lost credibility.  Sadly, you’ve also lost the credibility to comfort the child afterward.  In this way, I do not try to hide or gloss-over my concern for a baby that doesn’t gain weight as expected.  I try to take a measured and reasonably algorithmic approach, however.  It doesn’t scare me, and I have a lot of experience and knowledge.  If one thing doesn’t work, we’ll try another.  I will not give up.  When I’m concerned, I tell the parents and then do something about it.  Having a plan, indeed a whole decision-tree of analytical approach to uncertain events, can be a crucial tool in the management of complex problems and the anxiety these provoke.

But I knew, and she knew, that Henry was gaining weight just as expected.  The nursing was going well.  As described in the last post, she had not expected the appearance of her breasts to change.  I felt bad that I hadn’t expected this either—at least not overnight.  I had not warned her of this possibility.  At first, I thought she was concerned if her baby was getting enough, so I reassured her about that.  Then it appeared her concern was that her breasts no longer seemed to appear full, and she was worried that this might be a sign of a problem with her milk supply.  I reassured her about this, too.  One by one, I asked her about her concerns, and one by one I dealt with them in the best way I could figure.  Seriously, thoughtfully, and, I hoped, kindly.  On the phone, I thought I was getting her past this buzzing cloud of anxiety.  I didn’t expect her to ask if the baby was going to survive.  For that, there was no answer on the phone.

I know about the dark places.  But I can’t make them go away.  If they are prominent in the moment to moment thoughts we need to have to get through our daily tasks, they interfere with doing what we need to do.  They sometimes interfere with what our children need.  They always interfere with what we need.

I didn’t ask what she meant when she asked if I thought the baby would still be there in 6 months.  I just got her address and told her I’d be there in a few minutes.  I didn’t ask her permission.  I didn’t ask if it was a convenient time, or if there was somebody else she could call.  This was not a time to be afraid to step up to the plate.  I stopped briefly in the supermarket across the street.  I bought a small serving of macaroni and cheese (usually quite bland at the place near my office) and a small amount of freshly cut-up watermelon.  I went to her house.  That’s coming up in Part 2.

August 11, 2010

Boob Job 2—Breastfeeding in the Real World

In the last post, I mentioned getting a call from Amy, a first-time mother.  She’s nice, very intelligent, very well educated.  She has a good sense of humor and a nice husband.  When they took baby Henry home a few days ago, he looked great.  He was losing weight, as expected. 

Usually, babies are born with a store of extra fluid.  For the first day or so, it’s not unusual for them to sleep nearly all the time.  They aren’t hungry yet, and a lot of their energy is taken up just keeping their body temperature stable.  Sometimes a new mom is worried by this.

Some breastfeeding books—and advisors—convey the idea that a newborn baby is completely driven to nurse from the moment of the first breath.  It’s true that babies have rooting and sucking reflexes when they are born, and that they can nurse if it’s available.  It’s unfortunate that some new mothers get the expectation that their newborn will nurse immediately and often during that first day.  Though exhausted by giving birth, some first-time mothers just can’t put the baby down.  Having pestered Santa for 9 months about that big toy they’ve been wanting, they finally see it under the tree.  Now that it’s open, they don’t even want to go to sleep and miss precious playtime with it.  The baby has also usually had a pretty exhausting first day.  It’s not unusual for a baby to sleep 22 of the first 24 hours.  So I hear a lot of concern and disappointment when I’m told that every time the baby is put to breast, he falls asleep.    

The problem with unrealistic expectations about nursing, of course, isn’t that they will result in a less-healthy baby.  They will, however, cause the mother to question the viability of her plan to nurse, and question her body’s capability to make milk.  I put this squarely on the culture of breastfeeding, at least in the community I’m in.  The books make it sound easy, painless, and problem-free.  This, as I’ve said, is counterproductive. 

It’s been a revelation for me to see the peer pressure at work in my community.  That clique of mean ‘popular’ girls in high school has morphed, at least here in Berkeley, into the competitive breastfeeding league.  They are the women who see a mother in the park and through warm smiles tell about nursing their baby blissfully and without problems.  Until high-school.  They won’t fail to tell horror stories about the ground-glass and petrochemicals in baby formula, the hormone-like bisphenols in baby bottles that are so potent that you might as well start saving now for the kid’s gender-reassignment surgery.  Not that there’s anything wrong with that.

As if these pressures aren’t enough, new mothers have a lot to cope with.  Their lives have been turned upside-down, their careers are, at best, in limbo, their relationships have changed, they aren’t getting enough sleep, their breasts have changed, their privates have changed, and they have—did I mention this?—a baby.

I’m prepared for breastfeeding questions and problems.

Amy said that she had a couple of questions.  She said she was worried that something was going wrong with nursing.  Over the prior few days, as expected, her breasts gradually would become engorged, and she had been producing milk.  She knew it because she would leak milk.  When Henry nursed, she could hear him swallowing, and some milk would leak out of his mouth when he was done.  I told her that was great.  But this morning, when she awoke, her breasts seemed different.  They seemed both to be kind of deflated, flatter.  Not painful or red.  Henry seemed completely satisfied when he nursed, and was audibly swallowing as ever.  She was still leaking.  I found this all pretty reassuring, and told her so.  I asked if she had ever seen a nature-show on TV or a National Geographic article that showed women who nursed their babies but don’t have bras in their culture.  They just aren’t, I pointed out, perky.  There’s a reason, after all, that Frederick’s is ‘of Hollywood’ and not, for example, ‘of Manaus.’  Appearance and functionality are simply not linked.
amazon woman
It’s worth mentioning that for most of their lives, women get strong messages about their appearance.  Men do too, of course, and I speculate that the pervasive influence of visual media has tended to increase the appearance-pressure on boys and men.  Still, women are bombarded.  In deep and subtle ways, these appearance pressures are all about cultural beliefs concerning attractiveness and ability to find and retain a mate.  Sometimes, as I create a dialog with mothers, they are concerned about the ways in which their bodies change.  It’s natural enough to think about this.  I wondered if this was the basis of her concern.

She said she was concerned that the baby wasn’t getting enough.  This was the most common concern of new moms who breastfeed.  I’ll point out again that  though the words are about infant nutrition, the meaning is all about anxiety.

I asked her to relate the entire day up to the time of her call.  She didn’t understand where I was going with this, but went along with my questions.  Every thing she said she did—even getting out of bed—was coupled with a question from me.  “Did the baby have a wet diaper?  Did you change him?”  By the time she got to our phone call, about 4:30 in the afternoon, she had changed at least 8 wet diapers, most of which had a little bit of soft yellow poop.  It was a revelation to her that he went through that many diapers.  It’s a normal amount.  I asked what else she fed the baby.  She was confused by this question and a little shocked.  Nothing else, of course.  How about her husband?  Did he take the baby to a drive-through window for a bacon double-cheeseburger?  Of course not.  So if the baby is having about a dozen wet diapers a day, he must be getting plenty of fluid from someplace.  If it’s not the all-you-can-drink fountain dispenser at a fast-food restaurant, it must be from her.  She embraced this reassurance.

I also made the following offer.  She could bring the baby to the office every single day and use our baby scale to weigh the baby.  The scale doesn’t lie, doesn’t give exaggerated reassurance.  If the baby is gaining weight appropriately, she’ll see it for herself.  If not, I’ll be right there to make whatever changes are needed.  I will not let her baby, or her, fail.

As an aside, I strongly discourage anybody from getting a baby scale in their home.  It is not useful in feeding management for healthy babies.  It is both a material manifestation of psychopathological anxiety and a prop that enables and exacerbates that anxiety.  It doesn’t help the baby.  By the way, I have recently been hearing about new parents who are advised to take their baby’s temperature daily or several times a day.  Even if it weren’t ironic, I would really advise most of these parents, too, to chill.

Each of these reassurances seemed to help.  I felt like I was helping her.  She asked me,  “Do you think I’ll still be nursing in 6 months?  I mean, you know, if he’s still…here.”

I said, “Give me your street address.  I’ll be right over.”  I got in my car and was there in moments.  That’s the next post.

August 8, 2010

Boob Job—Breastfeeding in the Real World

breasts-oxcart When Amy called, she sounded fine.  She’s in her early 30’s and just had her first child, a great and healthy baby named Henry.  The baby was about a week old.

In pediatric training, I wasn’t taught much about the mechanics of breastfeeding.  Sure, I was taught that it was a good thing.  I was taught to encourage it.  But how the process happens, how the machinery in the breast works or doesn’t, and what some of the key practical issues might be was all unexplained.  Luckily, I used to work with a fabulous nurse-practitioner, who is also a lactation consultant.  She taught me a ton, and I have learned more since.  So I’m no longer afraid of dealing with nursing issues head-on.

Before she left the hospital with the baby, I had told Amy what to expect, in general terms.  I told her that most women who are mothers for the first time don’t usually make a lot of milk for the first few days, maybe more.  But in order to get the factory going, she needed to keep putting the baby to her breasts.  It’s nature’s way to have the baby get hungrier over those first few days.  The baby gets hungrier, sucks harder, sleeps less and wants to nurse more.  This results in more stimulation, causing more hormone release from the brain, causing milk production.  As the milk starts coming, the baby gets some positive feedback from nursing, leading to a completely Pavlovian conditioning system, which leads to the baby wanting to nurse more, leading to more stimulation, leading to more production, and the next thing you know, you’re getting a bill for college tuition. 

Nearly always, I’d give new parents this speech or something close.  I started doing this because again and again I have had to reassure new parents that it was completely normal to have a 2-day-old baby who wants to eat but mom has nothing to give.  Colostrum, the early secretion of a breast, is very healthy for the baby but not very filling.  Though I haven’t found this written about much, it’s just this anxiety which seems to have coincided with abandonment of breastfeeding in patients I saw years ago.  The parents would care so much about the baby that they would draw a premature conclusion that their ability to lactate successfully had failed in some way, and start giving the baby formula.  Formula isn’t poison, no matter what you’ve heard.  Sometimes, it’s necessary and I recommend it.  But once a baby starts eating from a bottle, they learn that this is the way to eat.  It’s much more work for a baby to extract milk from a breast, and takes much more coordination of breathing, and sucking pressure.  So even after there’s a decent milk supply, the baby will nurse briefly and then complain, preferring the bottle.  They are saying that even though they like home-cooking, they’d rather go to the drive-through window and get fast food.

Honestly, I think that taking the time to explain what to expect has resulted in very few breastfeeding failures.  I’m very grateful, as well, for being in a community in which lactation consultants are available and can be enormously helpful.  Though I have a lot of the same knowledge, and am completely comfortable around nursing babies, I’m still a little awkward when it comes to judgmental assessments (‘wow, now that’s an inverted nipple’) and manual intervention (‘OK, push your breast this way, squeeze here, and massage your nipple like this’). 

It may be counterintuitive, but I think one of the smartest things that I do with breastfeeding promotion is give the parents some formula.  Hospitals used to give formula samples, provided by the manufacturers, to all the parents of new babies.  I’m against this.  It sends the wrong message, and some hospitals have stopped doing it.

It’s different when I do it.  I give the parents a small amount.  Sometimes I have premixed little bottles in packages of 4.  I like giving those.  Sometimes I have cans, and that’s OK if it’s all I have available.  I get these from the same manufacturers as the hospitals.  This isn’t formula to feed the baby, though the manufacturers would certainly like me to promote it as such.  It’s an anxiety-relief apparatus, which works at many levels. 

First, by coming from  me, I am implicitly granting permission for the mother to use it if needed.  If she decided she needed it, it would be OK.  I’d tell her that she should just keep it in the kitchen cabinet, just to have it on hand.  I tell parents that I don’t expect it will be necessary.

I’m not much of a back-country camper.  The whole idea of a bivouac is unappealing to me.  But I know plenty of people who love the outdoors and the idea of following a Road Not Taken.  Oddly enough, they still take along a cell phone.  Just in case.  Just because you don't anticipate a problem doesn't mean that you shouldn't have a contingency plan.  Maybe it's the cell phone, maybe that wacky silver emergency blanket.  Just having it along can give you the sense of security you need to go someplace that otherwise would be too scary to go.

Second, it’s a message that I won’t let their baby fail, and neither will they.  When a new baby comes home with a first-time parent, our insular society has precious little support to offer.  Other cultures, and our own of 150 years ago, provided a multi-generational household.  Several generations of women would be there waiting with a deep repository of knowledge and experience in nursing and babies.  If your milk didn’t come in easily, there was other milk available that would get the baby through those first few days.  My experience was that many or most of the women who turned to formula could, in fact, nurse successfully.  What they could not do was wait.  At some point, their anxiety about feeding the baby crossed the high threshold of their desire to breastfeed.  They wanted to make it work, but they couldn’t stand another moment of knowing the baby wasn’t going to get anything to eat.  This wasn’t bad parenting, it was good and loving instinct. 

I wrote a blog post about The Telephone Paradox.  The more I gave my home phone number to patients, the fewer calls I got.  None of my physician colleagues believe it.  I found that when patients knew and really believed that they could contact me at any time, they were empowered.  If the kid had a fever, they wouldn’t call immediately.  They’d try some fever medicine, knowing that if it didn’t work, they could call later.  Usually, it did work, so no call.  The parent was made to feel that they had the power to try what their common sense suggested, and that I was there if it didn’t work out as hoped.

So that formula in the kitchen cabinet usually sits unused until it’s past the expiration date.  The new mom is empowered by it.  Maybe she can get through just one more night with a hungry baby, maybe just a few more hours even.  If she needs it, it’s there.  But for now, she’ll keep putting the baby on the breast, doing what she needs to do to get that machine started.

I asked Amy if the baby was all right.  She said that the baby was fine, but she had a couple of questions.  They didn’t go where I thought they would, but that’s the next post.

August 3, 2010

Mystery Diagnosis—Mom’s Wrist

More than a year ago, I wrote about a little-known entity that I have sometimes diagnosed in a mother who is complaining about wrist pain.  Called Nursemaid’s Wrist, it is hard to find online or even in many medical textbooks.  It has nothing whatever to do with Nursemaid’s Elbow, which is something that kids can get.  Nursemaid’s Wrist is a pain in the wrist that adults, usually mothers or those who care for infants, get from repetitively stooping to pick up a baby.

It’s easy, of course, to underestimate the weight of a baby.  The average birth weight these days is over 7 pounds, and by the time the baby is 4 months old, it might be double that.  If the baby were a bowling ball—professional bowler weight—it would seem quite heavy.  A 4-month-old weighs about the same as a 2-gallon container of water.  It’s easy to see how someone lifting and moving that kind of weight can get sore.  But they are moving that object with considerably more care than they might a plastic jug of water or a bowling ball.  The muscle tension required for fine movement control while holding on to a heavy weight puts an enormous strain on the whole mechanical system.  Some muscles of the body seem well designed to handle massive enlargement and strengthening if circumstances required it.  Biceps and shoulders, and the muscles of running and leg movement are good examples.  Except for a protective covering of skin, they have a good blood supply and can pretty much expand from exercise to whatever size is needed.  Though we’ve all seen photos of shockingly-massive bodybuilders, much of the muscle size they have is in these muscle groups.  The fact that babies are considerably more adorable than, for example, steel weights, gives us the motivation to keep picking them up.  Weightlifters, however, are not looking to build up or enlarge those fine-motor muscles, which are usually invisible even in the most defined physique.

The wrist problem occurs because those fine-control muscles, of the hand and fingers and forearm, are threaded though a remarkable system of lubricated sheaths to keep everything operating smoothly.  They are threaded through notches to keep them from tangling or getting caught on angles of our bones and joints, and they slip through guide-channels so that they don’t restrict the range of motion of our joints.  With enough repeated exercise, just like lifting a barbell, those little muscles get stronger—and bigger.  If they get even a little too big, they start rubbing the inside of the sheath they pass through, they rub against each other, and they don’t slide as easily through their notches.  This leads to irritation, inflammation, and pain.  Carpal Tunnel Syndrome is the best known of these, but there are others.  Treatment is simple, if inconvenient with a baby around.  Immobilize the problem area, ice if possible, and anti-inflammatory medicine like ibuprofen.

This leads to the important question of this post.  The same question has come up before and probably will again.  What, exactly , is my job?

I’ve worked in other practices where the pediatrician’s job is reasonably clear.  Since I was paid a fixed salary and the practice was paid a fixed price per visit, there was constant pressure from management or the owner/partners to do as many visits as possible.  There was never any kind of incentive, even appreciation, for doing a good job, being thorough, ending a visit without the child screaming and traumatized.

When I started my own practice, I wanted to do things differently.  I knew, of course, that the business model of the factory-production design of medical-care delivery was the way a doctor could earn a living.  There are some really good reasons that nobody else practices the way I do.  Still, I wanted to have the feeling of taking care of kids and dealing with the whole person.

That sounds great, but it is so different from my training and experience that some really confusing issues have come up.  In the 8-minute pediatric visit, the doctor has decided that your kid’s upset stomach is from a virus and not appendicitis, tells you to keep up with fluids, and has left.  That, to be blunt, is the standard of care.  Teasing out the history of stomach aches, the recent weight loss, and a recent history of food refusal could take an hour, especially if the doctor actually tries to ask the child.  And what about symptoms in the parents?  These could hold an important clue to what could be going on in a child.

Where does my care of the child end and care for the parent begin?  All of my insight about postpartum depression stems from my belief that it’s not all about the mother.  It’s the mother-baby system that somehow isn’t working optimally.  Helping the mother is de facto helping the baby, who is indeed my patient.  In the same way, I would strongly urge any parent to wear a bicycle helmet.  My patient needs you.  Without a head injury.

Which leads to the case at hand.  A mother, mid-30’s, was in today with her baby.  The baby was fine, but mother was wearing black neoprene wrist supports.  I asked what was going on.  She said that she had been having wrist pain and went to her doctor, who told her she had carpal tunnel syndrome.  Here’s where my role gets confusing.  What could she be doing that could give her carpal tunnel syndrome in both wrists at the same time?  I didn’t think she was working in a parts-assembly factory or on a computer since the baby was born 3 weeks ago.  She wasn’t, she confirmed, and after asking her a few more questions, it was clear that this wasn’t carpal tunnel.  Do I tell her her doctor was wrong? 
hand with arrow1
She pointed to where it hurt, which was the same on both left and right.  Uh, that’s not where carpal tunnel hurts.  It wasn’t where nursemaid’s wrist hurts, either, and that was what I had been thinking.  I touched where she said it hurt, and she confirmed a little bit of pain.  I asked her to hold her hand bent in a certain way, then I pressed her thumb across her palm.  This hurt a little, too.  In this position, I pressed on the spot pointed out by the arrow in the picture above.  She jumped.  This was the Finkelstein Test—I’m not making that up.  I know, it sounds like an algebra mid-term from high school.  (He published this in the late 19th-century, I think.)  Her reaction led me to her diagnosis.

DeQuervain’s Tenosynovitis isn’t something that people assume they have.  It occurs mostly in women, mostly in their 30’s and 40’s.  It is thought that long before Dr. DeQuervain stuck his name to it more than 100 years ago, it was known as mother’s wrist.

If a little knowledge is a dangerous thing, what about knowing about the Finkelstein Test?  I suppose it would be right to say I couldn’t be positive about her diagnosis, but I was pretty sure this is what she had. 

Here are some of the issues for me as a physician:
  1. I’m not a doctor for grown-ups.  Do I mind my own business even if I think I’ve got a clue—and maybe they don’t? 
  2. Do I say something cautious like, ‘Maybe you should get another opinion.’  Isn’t my opinion another opinion?
  3. If I say, ‘Have you looked into DeQuervain’s Tenosynovitis?  It going around,’ what is the message I’m really sending?
  4. If I say, ‘I believe you have DeQuervain’s Tenosynovitis,’ what is my next obligation?  Do I have to treat it or suggest treatment?
  5. What if I’m wrong?
  6. How much work do I have to do, especially since I can’t get paid for any of it?  Officially, the mother is not my patient.

I found some information on DeQuervain’s Tenosynovitis on the internet and printed it out for her.  Treatment required a completely different kind of splint, which I also described.  I don’t know the name of her doctor and didn’t ask who it was.  But I deeply suspect that there were only a couple of reasons that she was still suffering in pain.  Either the doctor didn’t know about this unusual diagnosis, or didn’t listen carefully enough to the patient.  It was in her description of the the problem, the timing of its onset, and the exact location of the pain that eliminated diagnostic possibilities like carpal tunnel syndrome.  I think these are both potential problems:  a doctor who doesn’t know or a doctor who doesn’t listen.  Nobody can know everything, and this is an unrealistic goal.  But it would be great if doctors would spend the time to listen carefully, and then be open about not knowing.  When that happens, good doctors hit the books.

As a closing aside, this is an ongoing pattern in Every Patient Tells a Story, a book about unusual diagnoses that I like a lot and reviewed in this blog a while ago.  Though the author was kind about it, the first doctor to see these unusual problems often didn’t make a correct diagnosis.  But at some point, all the patients described finally saw a professional who wouldn’t give up, even if they didn’t know.  They reasoned it out, did what homework was needed, and got to the diagnosis.  Of course, they weren’t paid more for this extra work than the doctor who said, because it would take the least time, ‘carpal tunnel syndrome.’

4/3/2011:  A commenter asked for suggestions.  This blog doesn't give medical advice.  Indeed, I don't think it's a great idea to give medical advice without some kind of an examination.  Of course, that never prevented my mother from giving medical advice.  But I will tell you what I recommended for the mother written about above.  Exercise:  this problem, like other repetitive-use types of problems requires rest, not exercise.  Stretching just to the point where pain starts might be helpful, along with ice on the problem area after it gets used a lot can help with inflammation.  As described above, I suggested that the mother get a 'hard' splint, one that will hold her hand and wrist in a fixed, natural position, and will tend to prevent her from holding the baby's weight on the painful muscles and tendons.  I told her to get a wrist splint that wrapped around the thumb, and had a rigid (usually slightly bendable aluminum metal) spine on the wrist/palm side to hold her hand in a comfortable but fixed position, even when picking up the baby.

July 30, 2010

A Baby with Diarrhea

The mother that called me wasn't in a panic, and that's usually reassuring to me. She told me that her 3-month-old baby had diarrhea for 3 days. At that age, with nursing well-established and generally consistent growth, they can usually weather a brief illness without too much difficulty.  But I asked the usual questions. He didn't have fever or a rash. He didn't seem to be in pain, he wasn't unusually irritable. In fact, he was nursing as usual, seemed happy and playful as usual, and was having a lot of wet diapers, as usual. But he was having diarrhea in small amounts a dozen or more times a day.  It started 3 days ago, and nobody else in the family was sick. Did they change what he was getting? I wondered if they had started to introduce a baby formula to which he was having some sort of reaction.

"No formula," his mother said. "Except...," she paused here with a giggle. “Well,” she said, “we were in McDonald's and the baby was hungry and he kept looking at us and seemed to be grabbing at our food.  So we took a little piece of cheeseburger, kind of mashed it up, and fed it to him.  He really liked it!  We were careful not to give him a lot though.  Everybody knows that kids shouldn’t eat too much fast food.”  The diarrhea started the following day.

“Oh,” I said.  “Uh…did you give him anything at home?”  I had a feeling about what to expect.

Well, he liked the cheeseburger so much that we wanted to see what else he’d like.  We were having spaghetti, so we gave him some of that.”

Sauce of some sort with that?”

Of course.  Who eats spaghetti plain?”  Not 3-month-old babies at their house, for one.  Within the last 3 or 4 days, the baby, who had never had solids before, had at least a little bit of cheeseburger, pasta, marinara sauce with meat, mushrooms, at least 2 different kinds of sausage, several breads with and without butter, and just about everything else the parents ate.  And, the mother pointed out, “He really liked the ice cream.”

Usually, the first solid food we introduce to babies is rice cereal. Sometimes it's as early as 4 months, sometimes as late as 6 months. Much later than that is still compatible with life, of course, but the nutrition seems to be less complete, the child doesn't learn the skill of eating, and the maturation of the digestive system is delayed. Aside from This Island Berkeley,this_island_earth_1954 perhaps, places where nursing is the exclusive source of child nutrition extending well beyond a year are usually places of great deprivation.

The recommendation of starting with rice cereal has some sense behind it. You may know people who have reactions to wheat or just trouble digesting it. But though possible, this is much less likely with rice. It's reasonably inexpensive, and readily available in the supermarket, fortified with iron. It can be mixed with breast milk, formula or water. It cam be put into a bottle or made thick enough to stand on a spoon.
The iron is important. Formula in this country is fortified with iron. Breast milk has little iron, but what it has is especially absorbable to the baby. Even in Red States, babies don't generally get a lot of beef or related high-iron foods until they are walking. As the first year goes by, the store of iron-rich red blood cells inherited from the baby's mother are gradually used up.  By 9 months or so, these are all gone, and babies whose diets are low on foie gras don't have a lot of concentrated dietary sources. That's why we test every 9-month-old for iron (hemoglobin level, actually) at their well-child visit.

Here's what happens, as every parent knows. The first time a spoon of cereal goes in their mouths, babies scrunch up their faces and scrape the stuff off their tongue and out of their mouths. Never having had anything like this before, they wonder why you are putting a spoonful of what could be sand in their mouth.   It had never occurred to them that food could come in some form other than liquid.  They get the idea eventually, of course.  This process, often requiring patience and persistence, is important. It's not the nutritional value of the cereal that's so essential. It's the learned skill of manipulating solid food in your mouth to get it to go down the right way without choking. We've all had that horrible sensation, and we've had a lot of practice. For a baby, this is a skill for life. Still, rice cereal is bland and not every baby likes it. 

This is a good spot to tell an absolutely true story, which I freely share with many first-time parents who struggle with teaching a baby to eat.  In my graduating class at medical school, there were about 100 graduates.  Every one of them—with no exceptions—was on solid food.   At this point, most of these exhausted and frustrated parents look at me and wonder if they picked the right doctor.  Every one of my medical school classmates, I assure them, learned to eat solids at some point between being 4 months old and medical school.  Though I couldn’t say exactly when.

I’m happy to report that the baby with diarrhea didn’t have a dreaded infectious gastroenteritis.  Or if he did, it just happened to resolve at the same time he stopped getting his meals at a drive-though window.  Do you want fries with that?

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July 27, 2010

Mystery Diagnosis--The Streak


Sometimes it’s easy to figure our why parents call when they do.  If a child is sick, most parents have no problem recognizing this.  Most people are empathic enough to sense when a person has difficulty breathing, or is in pain or distress of some sort.

Sometimes, this is a language problem.  It’s probably not a great idea to speak loudly about a movie that bombed at the box office while going through airport security.  And it always gets my attention when parents tell me that their baby had a hard time breathing last night.  True, a complaint like this is one that will usually get a doctor’s attention.  But if you take advantage of this too often, the doctor could decide you are just crying wolf, and gradually take your complaints less seriously.  

Today, a nice couple came in to the office with their baby.  They had been up all night and said that the baby was having trouble breathing.  I sat up.  Maybe I didn’t really sit up, but instead slouched a little less than I usually do.  After several minutes of interrogation-like questioning, it was clear what the baby’s real problem was.  He was having trouble breathing…through his nose.  This can be a real nuisance for a nursing baby, since they can’t really nurse and breathe at the same time with a stuffy nose.  Still, from the doctor’s point of view, it’s a long and reassuring distance from having trouble breathing.

There are also parents who are generally less anxious.  I try and fail to contain my surprise when a child is brought to me with severe symptoms that have been going on for a long time.  Every doctor has cases like this, some tragic.  For pediatricians, a typical example would be asthma.  Several times a year a child comes in whose parents say that she’s coughing.  For how long, I ask.  ‘Maybe a year,’ they say.

I don’t fault these people.  If the kid was really in trouble, they would have sought help right away.  For some, coming to the doctor is a logistic nightmare consisting of taking time off from work, getting the kid transported, parking expenses, and lots of other incidentals.  (As an aside, it’s easier if the kids actually like going to the doctor.)  Besides the general pain-in-the-neck quality to doctor visits, there’s a natural inclination—often correct—to believe that medical problems that aren’t too bad will probably get better on their own.  Even though I am often sent unusual and difficult cases, many times I have to tell parents that I don’t know what is causing the symptoms they report.  

This brings up an extremely important but subtle part of good medical education and experience.  Some people believe the smartest doctors can diagnose the most exotic problems.  That’s certainly a great and useful skill.  But in primary care practice, especially pediatrics (and, I suspect, geriatrics) where the patients often can’t answer your questions, it’s often most important just to be able to tell worrisome or not.  So though I didn’t know exactly why the baby was congested, I had no idea why the baby was fussy last night, and I didn’t know if the fussiness would happen again tonight, I was confident that the baby was generally OK and would continue to thrive despite having a stuffy nose.

This ability to assess some kind of worry-worthiness grading system seems to be in all of us.  Obviously, some are more anxious than others, and they will grade a threat-level higher than others.  

So it’s not bad parenting that led to the call I got about 4:30 this afternoon.  A mom called and said that her daughter, 6, had a rash.  How long had the rash been there?  At least a month.  I asked more questions, and they decided to come to the office and let me take a look at it immediately, which I did tonight.2010-7-20 lichen striatus-Kayla vertArrows  

Memory is a funny thing.  Sometimes a visual image will stick out like a stone in your shoe.  It’s pretty common for people to say that they know they’ve seen something before, but have trouble placing just when or where.  And I wish I knew why people can look so familiar but I just can’t come up with a name.  This happens to me locally all the time.  Someone will stop me in the supermarket, for example, and say, “Hi Dr. Wolffe.”  I return the greeting but don’t even recognize the person.  Then from another aisle comes grandma with the kids, and I’ll know exactly who they are.  I’m so focused on the children when they are here in the office that sometimes the adults look familiar, but without the kids they are sometimes hard to recall.

The mother said that this girl hadn’t been sick, and this developed over some period of time—she wasn’t really sure how long.  Maybe it was a week, maybe several weeks.  The girl said that it was itchy, but it hadn’t been scratched and she wasn’t scratching it in the office.  It was a little flaky, possibly a little red.  It didn’t hurt.  It had been there for at least a month.  It did feel a tiny bit raised, dry.  Mostly, though, the impression I got was that it was lighter than the surrounding skin and wound like the Andes from her upper arm to her wrist.

The first level of diagnosis, for me, is figuring out if I have to worry about it.  She had it for a month, for goodness sake, and the kid was none the worse.  She was happy and playful in my office.  I looked the kid over, and she was fine.  It’s certainly true that there are diseases that appear to get better and then return.  But most of the bad things generally just get worse, or at least don’t get better.  

The next question for me is if I know what this is.  I didn’t know.  But I knew I had seen it before.  But where?  What was it called?  I think that I am a reasonable diagnostician because I have real difficulty putting this aside and catching up with all the work I really have to do.  I eliminated the rashes that cause light streaks on the skin, but are there since birth.  I crossed off the ones that hurt or itch a lot or come from trauma of some kind.  And the ones that are very smooth or very rough or whorled like a cowlick.  So the diagnosis gradually came to me, but I hadn’t seen it in so long that I couldn’t be sure.  I excused myself from the exam room, and went to the computer in my little office.  It wasn't helpful.  I went to a reference textbook.  I looked up what it was…and I had been, well, close.  This was Lichen Striatus, a bizarre thing that preferentially appears in girls (no one knows why), of age 3-6 or so (no one knows why), usually affects a single extremity (no one knows why), and goes away by itself after some weeks to months (no one knows why).  No one knows what causes it.  It doesn’t seem to do any permanent damage, and generally needs no treatment.

(This is a good example, however, of the incremental information value of an analog book.  I was thinking right, and knew what kind of rash it was.  My first guess was indeed Lichen Striatus, but I couldn’t remember the right name.  I kept thinking, ‘Lichen…something.’  Honestly, I confabulated a last name for this disease.  I looked in the index for ‘Lichen Linearis.’  Seriously.  There is no such condition, and perhaps if my Latin training had been a little more thorough—or I had paid better attention—I would have realized this.  I had unintentionally taken a word from a real but unrelated problem called Lichen Planus Linearis (which I didn’t think this was), and stuck it in the empty spot, like a medical MadLibs game for doctor geeks.  I looked it up on the computer—but could not find the misnamed disease.  It was only when I went to the textbook and leafed through the index section starting with the word Lichen that a bell really rang for me.  Then when I saw the textbook pictures, I knew I was right.  This is the difference between going to the library to find a book on the shelf and getting the book, fully scanned, online.  Sometimes what is most valuable isn’t what you’re looking for, it’s what’s next to what you’re looking for.)

I forgot to ask the mom why, today, she called to have the child seen.  I’d be interested.

July 23, 2010

Headache in a 5-year-old

Molly, 5, had an eye problem. It was pretty common, and her eye doctor recommended that she wear a patch on one eye several hours a day. She didn’t mind this, and she and her parents picked out all different designs for the patch that might suit her mood or fashion requirement. Usually, the patch is worn over the stronger eye in order to force the weaker one to get more exercise. 

So when her mother told me that she had a headache, my first guess was eyestrain. It's a common cause of headache at almost any age. But still, 5-year-olds don't often complain of headaches.

Her mother was sympathetic. She told her child that she'd get some medicine for her that would help her feel better, and went to the cabinet where they keep the acetaminophen. It was only a few steps away, but Molly started crying. She said that it was still hurting. Mother repeated that she would give her some medicine that would help. Molly said that it wouldn't help. Mother said, calmly, that she thought it would and that after the medicine they would lie down in the bedroom together until she felt better. Molly said that it wouldn't help and that it was going to get worse and it was getting worse right now and she didn't know what was going to happen and that it was still getting worse and medicine isn't going to help and nothing is going to help and she was really scared. Molly was screaming by now, continuing to express her fear and pain. Mom had picked her up, of course, and was doing her best to settle her.
She did the best thing she could think of, and took her into the bedroom. They lay on the bed together, with Molly in her mother's arms. Soon, Molly fell asleep and was better a few hours later when she awoke. When mom told me the rest of the story, I told her I wanted them to come to the office so I could speak to Molly in person.
Fortunately, Molly is smart and talkative and likes me as much as I adore her. She told me that her eyes didn't hurt when this happened. Her mother told me that there really wasn't a family history of migraine.
Though in my training I received a little exposure to migraines, even now this is generally thought to be uncommon in children. I have a feeling that isn't right. I have diagnosed migraine in children as young as 5, and there is often a family history. Their symptoms are usually just like adult symptoms. I wonder if these kids have headaches or stomach aches from even younger ages, but lack the expressive language to tell us. In this way they suffer without relief, and their doctors never get the clues they need to make the diagnosis. I would guess that a toddler with a headache is pretty cranky. So I wonder if some emotional or behavior problems in these younger kids--who knows? maybe babies, too--could be resulting from this kind of invisible problem.

But Molly didn't fit an identifiable migraine syndrome. She didn't have any problem with her brain that I could find. 

I asked if she would get headaches when she was outside in the bright sun. Her mom said that she didn't have one when they went to the local county fair the previous weekend. They were outside all day. They went to the petting zoo--but she didn't go in. Her brother, just 2, had no hesitation and had fun with the gentle animals. In fact, the closer she got to the fence around the petting zoo, the more upset she had become. She even was scared to see her brother near the animals. I asked her mother about other things she was afraid of. 

The list was long. She was scared of just about any animal that was live, any bug of any kind but especially spiders, snakes, dark places including closets and under the bed. I asked Molly, and she was open with me. She said that she was afraid of being separated from her family, she was afraid that something bad would happen to her mother, to her father, to her brother, to all of them together, and to herself. She was afraid of strange and new places, new foods. She was afraid of snakes. 

Now, with a little more insight, I asked her about the headache. She said it had hurt. This time I asked her more about what she was feeling during the headache. She said that she was very afraid that it wasn't going to get better. She was afraid that her mother wasn't going to be able to help her and that would make her mother feel bad and it would be her fault.

It's always concerning to me when a 5-year-old complains of a headache. I think Molly had a headache, and I'm not sure what caused it. But though it's not in my textbooks, this is what a panic attack looks like in a preschooler. When I told her mother this, she was able to think of a couple of other unusual meltdowns that seemed to come out of nowhere. They weren't for the usual reasons, when a parent says that the child can't have ice cream for dinner or has to turn off the television. They weren't about defiance, they were about worry. And each time, her mother felt powerless to stop them. In many ways, these events might look behavioral. They include crying, perhaps screaming, maybe pounding fists or feet.

It's the panic attack that made her reaction spiral out of control. Her mother had the right treatment for a headache. Some acetaminophen, closing her eyes in a dark quiet room. But I had to give them something that could make the panic attack less traumatic for the child—and maybe for the mother, too.

Panic_in_year_zero_1962_poster I gave the mother a pair of questionnaires I give to parents to help me evaluate anxiety disorders in children. The responses were convincing.

Though Molly had a clear anxiety disorder, she had some big potential advantages as I considered her treatment options. She was smart, she was verbal, and she wasn't afraid of me. The first two points would enable her to cooperate in her treatment in important ways. The last one would, I hoped, enable her to accept my guidance without her anxiety interfering. I discussed treatment options with her mother. She, too, thought that Molly's particular trust in me was worth exploiting to help her. 

Often, with generalized anxiety that includes aspects of the diagnostic subcategories (such as social anxiety disorder, separation anxiety, phobias, and so on) medication is a reasonable approach. But we had these advantages, and her mom and I wanted to try and take advantage of them. We could always revisit a medication option if other approaches didn't work.

I could have sent her to someone really good at Cognitive Behavioral Therapy. In 5-year-olds.
This approach is designed to help patients recognize their dysfunctional thoughts, and manage them in a rational way. Though the technique is well-known in adult psychotherapeutic circles, it's not so well developed for kids. And certainly not with preschoolers. 

In the bigger picture, however, the effects of Cognitive Behavioral Therapy, I think, can be thought of in the same general pool with meditation, yoga, prayer, and clinical hypnosis. They all help people (nothing works for everybody—each helps some people) get relief from thoughts and feelings that are painful or harmful.

What her mother decided was to let me try to teach her self-hypnosis. 

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July 18, 2010

Vaccine Refusal and Ethical Issues

All the families who bring their kids to see me know that, in general I’m a supporter of childhood vaccination. On balance, the risk to your child of a devastating or lethal disease with known and terrible effects seems to dominate the risk of vague eventual possibilities of problems that are either unproven or completely debunked. This post is not about why you should vaccinate your baby. Though you should.

I’m in a pretty privileged position. None of my patients comes to me just because my name was on the list from the insurance company. A parent picked me, researched me, got my name from a friend or coworker. Sometimes, I’m gratified to say, they get my name from a nurse in Labor and Delivery or from one of the lactation consultants or midwives. Some of my most difficult cases come to me on the recommendation of my pediatric colleagues who have practices of their own.

So it’s what is generally called a self-selecting group. They are here because they want to be here. When parents expecting their first baby come to interview me, many don’t know my views on vaccination. Perhaps it’s a result of being located here in Berkeley, but I don't get parents who have heard that vaccines are harmful, and want to learn my professional opinion. I get those who say they want me to be their child's doctor because they have read or heard about me, but have made up their minds about vaccines. I wonder what they really want from me. If they don't want my medical expertise, they why are they coming to me? How can I help them? I hope that I will always provide the best care I can, but I was not trained in and do not know how to provide some reduced level of care.

What prompted this observation is a comment I read on one of the informational websites for physicians. A very smart academic doctor pointed out that when we treat families who refuse vaccinations, we are really being asked to provide substandard care. He argued that if we send these families elsewhere, we have lost the opportunity—perhaps many opportunities—to educate them and help them appreciate the value of this intervention.

It makes sense to engage with these parents. Most of them are extremely well-educated and literate. I would love to give them literature on the subject, cite references, tell them my own horror stories to counter the ones they heard from the internet, the parent group, or in the check-out line at the local organic market. I'd love to tell them that one of the local Montessori schools was closed twice in the last year by the Public Health Department for being a center of major pertussis epidemics. But I get the sense that they are not interested in receiving this information, or perhaps just not from me.

The parents of every child make essential health decisions every day. They manage the diet, activity, and safety of their children. Hopefully, they balance protection with freedom, and find a way to let the child ride a bicycle but still make them wear a helmet. I don’t think I’m the only one who is shocked when driving in a parking lot and a toddler is walking along without holding a grown-up’s hand, while they walk far behind, texting. That’s not OK! I keep my mouth shut when this happens, but I mutter unflattering things as long as my car’s windows and doors are closed.

But I am required, as much by my own standards as those of my state licensing board, to practice at very least at the standard of care. If the kid needs an antibiotic, I prescribe an antibiotic. For this reason, doctors shouldn’t be complacent with the nonvaccinating parents. It seems like a strategy of engagement is a reasonable way to go.

But I'm scared. In the past couple of weeks, I saw in my office a pair of former preemie twins. They are now about 6 and 8 pounds or so, and just got out of the intensive care unit. They are over 2 months old. Having unvaccinated kids in my office would seem to put them at substantial incremental risk. What is my responsibility to them?

That's not the only reason I have problems seeing unvaccinated kids in my practice. I feel so strongly about the importance of a meaningful doctor-patient relationship that I'm unclear about my role in their care. If I prescribe a medication to help your child breathe but you don't give it to your child, and instead use what your homeopath recommends, why did you consult me in the first place? If HIB vaccine could save your baby's life (or brain) but you refuse it, how much trust do you really have in me, my judgment, my training? It's better to bring your child to an advisor you really trust, whose expertise you respect, who can provide the care you really want and value.

I have absolutely accomplished one of the goals I set out for myself when I started this practice. I have patients and families that I know and who respect my guidance. This is probably a logical point at which to note that this doesn’t mean slavish obedience! I expect my own doctors to give me their very best professional advice, and in return I promise them—though this is unspoken—that I will take it seriously and do the best I can. I haven’t always followed what they suggested. Occasionally, I thought they were wrong, or didn’t understand all the aspects to my situation or complaint. Most often I just couldn’t do what they wanted. I couldn’t afford it, couldn’t spare the time, couldn’t make it work for me in some important way. But it has never been because I thought they were stupid, uninformed, or malicious. It wouldn’t say good things about me if I continued to go to a doctor like that.

So if I recommend that you let me painfully inject into your baby something you believe to be poisonous, toxic, or unproven, or if by recommending this your belief is confirmed that I am little more than a meretricious shill for the Big Pharma cabal, why would you want me to see your child?

Sometimes, when the prospective parents are interviewing me but before they storm out of the office, the reason comes out. I’m not really going to be their baby’s doctor. I’m the safety net for the naturopath, homeopath, or chiropractor who will really be managing the baby’s care. Then, if something goes wrong, they can bring the baby to me.

car seat
So the first ethical problem I have with treating families that don’t vaccinate is the fundamental nature of their request. They have asked me, with their full consent, to provide substandard care. When asked about this, a physician said that it was like the family refused to use a car seat for the baby. They ask the pediatrician, however earnestly, ‘What’s the best way to hold the baby while driving?’ Not only isn’t there a good way to hold the baby, but it would be unethical to do the research which could tell us if holding one way is 100 times more potential lethal than using a car seat but holding a different way is only 92 times more potentially lethal than using a car seat.

This is a line from a common translation of the Hippocratic Oath: I will prescribe regimens  for the good of my patients according to my ability and my judgment and never do harm to anyone. There isn’t much about doing less than my ability because the helpless baby has parents with...issues.

But the second ethical problem is obvious. Though it doesn’t come up in Hippocrates, it’s a central tenet in medical ethics. Autonomy. The patient has the right to make decisions about themselves and their treatments. With children, it’s generally understood that this means that the parents get this autonomy. When exactly this ends, by the way, is unclear. Legally, kids who are 18 acquire most of the medical rights of adults. This is confused, of course, if mom and dad are still paying for the health insurance. And, varying state by state, teenagers of a certain age can ask for and receive contraception or contraception counseling. Sometimes psychological services. Babies...not so much. Our society makes an implicit assumption that a baby’s parents have the best interest of the child at heart. Luckily and almost always, that’s true. The parents who choose not to vaccinate aren’t trying to hurt their baby, they are trying to protect it in the best way they know. Given this complete and unquestionable lack of malice, don’t they deserve the autonomy we all expect?

And one more thing. If a parent came to my office obviously intoxicated, I wouldn't let them drive home. Maybe I’d call a taxi, maybe I’d drive them home or call someone to pick them up. I would intervene in some way to protect them, their child, the community of unsuspecting and unwarned drivers on the road who all agree to follow some shared set of rules that protect them all. I don't know how to resolve this ethical dilemma between their autonomy and my responsibility. When they decide not to vaccinate, it's not like holding the baby without a car seat—it’s loosening the straps a little bit in every baby's car seat. What's my obligation to them?

So I think there’s a third ethical problem: my responsibility as a physician in the community, perhaps as a citizen. It would be wrong to cry out, ‘Fire!’ if there was none. But do I have an obligation to cry out if I see one?

July 16, 2010

Anxiety—College Boy Problems

handicapped sign
Before I met with Peter, the 21-year old college boy with anxiety, I asked his parents if there was anything they were concerned about. He said, “Well, it would be great if he were a little more outgoing.” I hadn’t seen the boy in a couple of years and didn’t really know him well since he didn’t go to the doctor much. Was he shy?

An hour or so later, with them waiting patiently outside the exam room, I knew he had a full-blown anxiety disorder. Many people have some anxiety in certain situations, like public speaking. Some people have more focused anxiety about specific things, like spiders or heights. Some have anxiety about things that they themselves know intellectually to be fairly harmless to most other people, such as a fear of balloons. Some fears are so unusual that the person is able to talk about them freely, and knows that they are not an issue for everyone else they have ever met, but the fear is quite real to them. Perhaps a great thing about the internet is that it can give this last group of people the ability to connect with the 1 or 2 or 5 other people who share their unusual problem. By example, there is a community, of sorts, for those with a fear of buttons.

He lived at home with his parents. There’s nothing wrong with that, of course. His parents were nice people and nice to him. And they never threatened to kick him out. They probably never would. That’s a nice thing, too.

But he never indicated that there might be advantages to living away from his parents. More than that, he couldn’t fathom why anybody his age would want to move away from home. It wasn’t like he was so emotionally tied to his parents. I had spoken with them, though not about him. They went on vacation, sometimes camping. They went out to the movies sometimes. Most of the time, I learned from Peter, he never wanted to go. I could picture a dysfunctional relationship in which he didn’t want them to leave, but he never objected. He was most comfortable just staying at home. Alone.

He wasn’t psychotic about his anxiety. He didn’t believe (or say he believed) that if he rode the bus then the world would end by a volcano emerging under his suburban town just as a meteor hit the earth causing an rip in the space-time continuum which would provide an attack opportunity for the Monsters from the Id.

Still, I had a bad feeling about where this was heading. Unlike the College Girl I had seen just a day before, he was not tortured by his anxiety. He knew that others weren’t as concerned as he was about many things, but the way he thought was obvious. Every unusual fear was completely reasonable, and he was almost bemused about the mad foolishness he witnessed around him. To him, our riding in vehicles of all kinds appeared like those who walk tightropes over great gorges. He saw that people did it, that they could do it regularly, but you’d have to be positively nuts actually to try it.

This is also how he saw the pursuit of human relationships. This was another big difference with the College Girl. She didn’t have a boyfriend and wanted one. She absolutely did understand why her peers were in or wanted to be in a relationship. She also understood what was keeping her from achieving this goal. She perceived her anxiety as a handicap that she hated, a roadblock she was desperate to overcome and was so far unsuccessful at doing so.

Was he really forthcoming with me? Like every patient, he was entitled to his privacy and owed me no explanation. Some doctors, I know, think that if a patient isn’t open about something, or if a patient fabricates something, then they can’t or shouldn’t help them. It’s certainly an impediment to treatment when a person doesn’t seem to respond to medication that they say they are taking but aren’t. But mostly if patients want me to give them my best advice and they want advice based on some hypothetical situation, that’s what I and they will be stuck with.

Is this denial? Once I saw a child who had been in and out of emergency rooms at least 4 or 5 times over several months. Every time the family went in with him, he had trouble breathing. He was given breathing treatments and medication and sent home to follow up with his primary care physician. They didn’t give him the medication, didn’t make the follow up appointments. They needed a form filled out for school, and the doctor told them that the child had asthma and would benefit from better control of his symptoms. They changed doctors, and came to the practice where I used to work. I told them their child had asthma and would benefit from better control of his symptoms. He went to the ER again, then they asked for their records to be transferred to another practice.

Is it my job to puncture his denial, if it is? Is it my role to judge his life decisions as somehow inadequate, as incompatible with happiness? Is my definition of happiness and success as an adult a reasonable goal? There are societal norms, of course, and he was aware of these. Marriage, family, work, kids, and so on. Certainly here in one of the epicenters of alternative lifestyles, there aren’t a lot of choices that wouldn’t be tolerated. Besides, I lived in Utah for 3 years. In ways that I appreciate more from a distance—topographical, chronological, and metaphorical—some of those people were very much willing to do a lot to live outside of the mainstream. Whether in shallow swamps of consanguine genes or in isolated heavily-armed bunkers waiting for the race-war end-of-times, they were going to do it their way.

Let me be explicit about some of the ethical issues associated with this case.

1. If the patient doesn’t think it’s a problem, is it a problem? Before there were Wall Street executives who didn’t take any responsibility in their congressional testimony, there was a panel of Tobacco CEOs who swore under oath that they didn’t believe that smoking caused health problems. That seemed sleazy and dishonest. But if a patient says that they are just fine with what they are doing, does it matter if they are in denial or are out of touch with reality?  Does the doctor have an obligation to do more than educate, inform, and offer help?

2. Is Peter hurting anyone else by his inattention to his anxiety disorder? Sure, his parents had dreams for him that might be difficult to achieve. But who among us has parents who have always thought that we would be exactly who we are now? I am, to be blunt, worried that what appears typical enough at the moment—a college kid living at home while attending a decent and popular local institution—could become more cumbersome as the years go by. Do his parents deserve a life of their own, without their kids? Do their kids owe them the freedom gained by moving the heck out of the house at some point? And the parents aren’t my patient, so should I care what they need?

3. I want to repeat that last part. The parents aren’t my patient. This is an easy issue for some of the patients I see. I have a patient who’s nearly 30 now, severely developmentally delayed. I have autistic kids who are technically autistic adults. It’s an easy issue for them because they have legal guardians and decision-makers. Not Peter—he’s warm and smart and going to college. But in some ways, obviously from these essays, I think of him as having a handicap. It’s not politically-correct, I know, to use that term at all. But there’s something about him, that is with him in every setting, that often interferes with his achievement of some of his own goals. It interferes, in my professional opinion, with his ability to meet some criteria of independent—if not happy, perhaps—adulthood. The Americans with Disabilities Act of 1990 says a covered disability is a physical or mental impairment that substantially limits a major life activity. What, if anything, should I tell his parents? That their kid is sick and needs to have medication spiked into his orange juice? I want to tell them everything. They are his best advocates, they know something isn’t right. He gets along well with them. Shouldn’t they be there to encourage him to seek the help I think he needs? A lot of parents read this, and would probably agree. But what about when you were 20—would you have wanted your doctor calling your parents?