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.