November 9, 2011

Media Ratings and Materialism

A recent study I read in one of my medical journals surveyed parents about media ratings. Not surprisingly, parents said that they liked the idea of a rating system to help them decide if certain content was acceptable for their children. The list of content they wanted notification about was extensive. It included all the usual suspects: bad language, everything even remotely suggestive of sex, private parts, and so on. The list of rated content included romantic situations, innuendo of every kind, violence seen and implied, derogatory terms, putdowns that kids say to each other (e.g. 'butthead'), and much more. The length and extent of the list shows the lack of consensus about what parents think is important. What is it that parents don't think is important?

But that's not the topic of this post. Embedded in the study publication was this item, which received no other discussion by the authors:

"Of all content types included in the survey, only 1 was not rated as extremely important or very important by the majority of parents: materialism or things that promote materialistic attitudes."

I report this from Berkeley California. In Berkeley, a nuclear-free zone, the sprawling Whole Foods market across from my office is filled with shoppers loading their fair-trade renewable-resource unbleached hemp-fiber shopping bags, filled with out-of-season organic produce flown in from New Zealand, into the back of the Range Rovers required to ensure the safety of their unvaccinated kids when driven by the au pair every morning a few hundred yards to the private Waldorf preschool.

I'm not in favor of unfiltered access by children to everything an adult or even teenage mind can imagine or put on the internet, in a game, or available some other way.

But materialism gets a free pass? Nearly all media produced with a child audience in mind is marketing. It is hard to find content, even content I love, without this. I think Monsters Inc. is one of the best movies ever made. But Pixar (and Pixar/Disney) has clearly taken a lesson from George Lucas, and licensed their trademarked characters widely. If I could afford them, I would have Monsters Inc Band-Aids in the office. It isn't unusual for your kids to see products in the store or owned by their friends and beg for them or ask to see the movie or TV show.

What about the materialism, not considered a problem by most parents, apparently, of so many of the television shows available on networks watched by preteens? Not limited to product placement, this materialism equates success with wealth, big houses, fancy cars, and so on.

I'm not a monk. I like nice things, fancy restaurants, and so on. I sometimes make purchasing decisions that in retrospect seem impulsive. But at this point in my life, I no longer believe these things constitute success.

I’m appalled that the parents surveyed identified depictions of materialism as unworthy of rating. They want to know if their kids will hear the word 'butthead,' but don't care that nearly all of the live action shows on Nickelodeon have characters whose goal is to achieve something financial or monetarily valuable, and they get general peer approval for it. For me, I would like to know if my kids are spending their screen time, no matter how strictly limited, watching infomercials for getting rich in the 'cash flow business.'

For what I suppose is the same reason parents don't focus on the aspect of media content, however, there is very little actual research done on this issue. So we don't really know how powerful this message is. But if it's like so many other subtle media messages, it gets a direct pipeline into the kid's brain.

Still, just like those other media messages, the real way to combat unwanted influences has been repeatedly shown to be modeling at home and not by media ratings. If the parents aren't confirming these media messages, they generally won't stick. So it's great to tell your kids they aren't allowed to eat snack food, but they see you on the sofa with a big bag of potato chips, you will need to do a better sales job. I guess I don't have to mention that all the lectures you received as a child (think back now) about the way you were supposed to act, the things you were required to do or forbidden from doing, just didn't take when you had the freedom to ignore these rules. While it's normal to push the envelope at certain developmental stages, we are most strongly influenced by what we witness our parents doing with our own eyes.

If you don't want your kids to use bad language, don't use it. For everything else, ask yourself 'What would I want my child to do?'

October 19, 2011

Breastfeeding Sucks

Self-deception is always a problem.  With me, it usually rears its ugly head in the thought that I don’t really need to count just this one little piece of chocolate.

So I can't claim to be shocked when I observe it in others.  I think it's a normal human trait.

But it has been a consistent and disturbing fact over my career that mothers are given information which is simply and obviously wrong.  I don't know it for a fact, but I suspect the problem is well-intentioned propaganda.

I admit that I can justly be accused, in an ad hominem argument against me, of being mammarily-challenged.  But that doesn't make it right.

My job, naturally enough, has brought me in contact with hundreds and hundreds of mothers and babies over the years.  Even mothers who have nursed many children say that at the beginning, it's quite painful.  Later on, when the baby is months old, they still say that almost always the initial latch causes a flash of pain.  (Once this latch pain is over, however, it's usually painless.)

It bothers me that the vocal, even militant, advocates for breastfeeding have so downplayed the discomfort associated with normal breastfeeding that they might be hurting their own cause.

I don't know for sure, but I suspect the authors of breastfeeding books and others resolutely claim that nursing is painless because they don't want mothers to be scared of trying it.  My guess is that they have wanted to give mothers, especially first time mothers, the idea that nursing is a blissful satori-like state in which your earth-mother womanhood will reach some sort of ultimate fulfillment. 

venus of willendorf

What I hear in my office, from every Gaia-aspirant, is very different.  The initiation of breastfeeding—even for mothers who have nursed many previous babies—is painful.  Let's face it:  nipples are a reasonably sensitive part of your body, and they are generally not conditioned to this use.  Many times a day.  Sure, babies generally aren't born with teeth.  But they can, as the expression goes, suck the chrome off a trailer hitch.  As if that's not enough, saliva is a digestive juice.  It might not be as irritating as stomach acid, but leave any skin wet with saliva and it will get irritated within hours.  (By the way, this is an important reason that toddlers using pacifiers often have a rash around their mouths.)

I have not seen a baby whose mother has not noted this pain.  Clearly, it's normal.  I don't think knowing about this pain would make a new mother avoid breastfeeding.  She just had a baby!  I think she can handle it.

Since I try to promote nursing, I've been frustrated by the mistaken expectation of new mothers that the process is supposed to be painless.  They often get the feeling that they must be doing something wrong, or there's something wrong with them, or there's something wrong with their baby.  Again and again, I have to tell them that the baby and their breasts are doing just fine, and what they are experiencing is normal.  I give them lots of suggestions for things they can try that might help.  And I am unhesitant to send them to a lactation consultant.

I suspect that some postpartum depression is worsened by this feeling of helplessness and inadequacy, that there's something fundamental wrong with themselves, or their bodies.  Their expectations for motherhood were so high, that this normal deviation from those expectations can't be anything but disappointing.  So I wonder if breastfeeding advocates have made it sound so effortless that many mothers switch to formula right away.  Some have told me that they think there's something wrong with them, and being good mothers, they want to be sure their baby is getting enough.  By formula feeding at the most painful time--often when the baby is 2-5 days old--they never produce enough to get the system working effectively.  They are afraid that they aren't able to produce enough, and sure enough, they can't.  This confirms their self-doubt.  But it's just something else for them to feel bad about.

I think it would be much more helpful to tell women openly what they should realistically expect.  At least they will be prepared and reassured that what they are going through is normal.

September 2, 2011

Pharmacogenetics and Race in the Medical Record

There’s a discussion on a physician site I subscribe to about whether ‘Race’ should be included in the general demographics information of electronic medical records.  Here’s the reason it should.  Now that we are every so slowly receding from the political correctness of the last couple of decades of the 20th century, medical researchers are finding out that there are differences in both disease risk and care for certain groups of people.  We’ve know for years that your child’s chances of certain genetic conditions were different based on your and your reproductive-partner’s genetic background.  Everyone has known that children of Ashkenazi Jewish heritage (more or less of Eastern European background) were at higher risk for a terrible genetic disease called Tay-Sachs.  Dark-skinned people of African descent were at higher risk of sickle-cell disease; white kids of cystic fibrosis.  Finally, in the last decade or so, researchers have found the freedom to study some important medical problems, and they have found out important things.  Here’s a good summary of some findings in the growing field of pharmacogenetics, which looks for differences in the response to different medications.

Racial differences in response to cardiovascular medication.  [It’s pretty readable for non-doctors.]

It has been found, generally speaking and for example, that there’s a difference in response to a common blood anti-clotting medicine in Black, White, Hispanic, Asian people.  This could be really important to know.  Though not a cardiologist, I have the impression that treatment guidelines have incorporated some of these findings, and you might get a different dose or medication depending on your ethnicity.

Have I sold you on this? 

We have always known that different people respond differently to a given medication or dose.  Sometimes doctors have to try different formulations or doses to get the therapeutic response that will help the patient.  Clearly, there’s something about the way that patient is metabolizing the therapy that is special.  Presumably, it’s genetic.  Note—it might not be.  Grapefruit and grapefruit juice, for example, is a very potent inhibitor of (and this is common knowledge) the CYP3A4 form of the P450 enzyme.  A lot of drugs get digested by this enzyme.  Blood pressure drugs, heart rhythm drugs, cholesterol drugs, sleeping pills, anxiety drugs, antidepressants, antihistamines, some birth-control pills, some immune-suppressant drugs and some anti-HIV drugs.  Chances are really good that you or someone you love is taking a medication affected by grapefruit, especially by grapefruit juice.  Organic or not.  Did the people studying these drug-responses ask their subjects about grapefruit juice intake?  I don’t know. 

I’m bothered by the idea of having an ‘Ethnicity’ in your child’s medical chart.

So far, a lot of the research in this emerging field of Pharmacogenetics (also Pharmacogenomics) isn’t.  It’s really PharmacoRacialist research.  There’s painfully little genetics and lots of studies of ‘racial groups.’ 

I’m not trying to be politically correct here.  I wouldn’t doubt that epidemiologic research done in a remote Chinese village is probably representative of a relatively limited genetic pool.  True genetic research in the U.S. has depended for decades on relatively closed and technically inbred communities among the Amish.  One of the reasons behind the excellent and expert genetics professionals in Utah is precisely the multigenerational stability and consanguineous inbreeding available for research.  Genetics research looks for a link between subjects.  A lot of this current research has only an ‘ethnic’ label as the common link.

Partly, it’s the government’s fault.  Seriously.  The Census is probably the most important way our tax dollars get divided.  And, perhaps with good intentions, the government wants to know about the ‘racial’ makeup of this country. 

As far as I can tell, this is the latest official information from the Office of Management and Budget, which manages the Census.  

US Census Directive 15

Everything is going to be bases on the census, and the racial distinctions are sociopolitical, no longer genetic or medically-based in any way.  If you think certain groups need to be kept track of, write your congressperson. 

From a medical ethics point of view, there is clearly emerging data suggesting that different treatments or approaches might be optimal for those with different genetic ancestries.  These distinctions are unlikely to overlap much with meaningless Census distinctions, such as 'Hispanic' (which, after years of debate, has apparently been changed to “Hispanic or Latino.”  The 'Asian or Pacific Islander' category will be separated into two categories -- "Asian" and "Native Hawaiian or Other Pacific Islander."  Hey, at least the islanders live on islands for pete's sake, at one point in the 19th-century genetically isolated in the Darwin-in-the-Galapagos sense.  My Korean and Chinese families don't think they are Japanese.  What about Filipinos or Indonesians where different islands can mean different origins.

I have a family with 2 Chinese grandparents on one side and 2 grandparents from Portugal on the other.  They recently immigrated here from Brazil--what are they?  What are their 2 adorable kids?Are they Latino because Portuguese is a Romance Language?  Hispanic because they are from South America?  Asian because the kids have those sort-of-Asian eyes?

There’s an easy reality check.  Ask the Spanish-speaking people you know.  Believe me (and the US Census), they are all around you.  When I lived in Utah, which I considered to be the least ethnically-diverse place I had ever lived, we had a medical clinic that was pretty much 90% Spanish-speaking.  These families lived right there among, well, you know who, in Salt Lake City.  Here’s what I have noticed.  Ecuadorians hang out, mostly, with their fellow Ecuadorians.  They may have travelled through Mexico to get here, and they speak the same language (to me).  When a friend from Venezuela went out with me in Boston many years ago, he could tell immediately that people we met were speaking with accents from Peru or Guatemala or Cuba.  I’ll say he could tell if people came from Puerto Rico, but he said that he couldn’t understand much since they spoke so fast and dropped so many syllables.  He sometimes complained that he was too impatient to wait for a Colombian to finish the sentence.   He could tell when they started speaking—but not by how they looked.  It was a revelation to me when I attended the wedding of a distant relative in Paris.  Also there were relatives from Nice (on the Mediterranean coast of France).  My relatives said it was impossible to talk to them because “…they speak with such a heavy Southern accent.”  It took me a while to figure this out.  It was hard for me to reconcile Hercule Poirot and The Dukes of Hazzard.

poirot Dukes_of_Hazzard_Wallpaper_10_1024[Tasteful?  Professional?  Oh come on, what did you really expect?]

I think this is an ethics discussion because even with demonstrable medical distinctions, how does the working doctor categorize the folks sitting in the exam room, and their variegated offspring?  Do we wing it on skin pigment (I all shades of dark kids and light kids from curiously mixed parents). 

My personal opinion is that the idea of race is a sad vestigial construct without helpful meaning.  Here's what I might need to know:  have any of the child's relatives had sickle-cell disease?  Cystic Fibrosis? Hemophilia?  It wouldn't help me to have a place on the chart for 'ethnicity.'  But in the Social History section of my computerized charting program, I will note if a child is adopted and from where.  I will note there if there are medically-relevant familial risk factors. 

And what about those medical distinctions I noted above that ‘everyone has known for years?’  Even if this were true for one very long historical era, until World Wars and intercontinental migration, it isn’t very true here in California.  When I first moved here from Utah in 1999, I made a comment to one of the hematologists at the local children’s hospital about not seeing much sickle-cell disease in Utah.  She said she had a clinic full of white kids with sickle-cell, and I felt as ignorant as I was.  Here in California, every baby is screened for sickle-cell at birth (since 1990).   Everyone has known, since 1885, at least, that Mongolian Spots (benign bruise-like markings often appearing on the lower back of babies) were much more common in Asian children.  This was first noted, as a fact, by Dr. Erwin Bälz [I couldn’t make this stuff up!], the German-trained personal physician to the Meiji Emperor.  It was only around 100 years later that these were found to be correlated with skin pigment—the more pigment you had, the greater the chances of a mongolian spot.  But they are harder to spot in babies with very dark skin.  So they were noticed more in babies of Asian descent who had more pigment that Laplanders but less than equatorial Africans.  Ira Gershwin said it best:  It ain’t necessarily so.

It turns out that the whole ‘ethnic’ idea is largely confounded by genetics.  It’s certainly true that my ancestry is tough to follow prior to immigration from southern Russia.  Nobody kept track of peasants and who they mated with.  Still, there are lots on great kings who have kids with serving wenches.  And from there, it’s all down hill straight to me.  Which leads to this:  I’m descended from Charlemagne.  Yes, that Charlemagne.  Perhaps less likely an ancestor for you if your family recently came from Africa or Asia.  Your folks came from Africa in the 19th-century?  We can both attend the Charlemagne family reunion.  Just arrived?  Maybe not Charlemagne, but definitely Nerertiti.  Just like me.  Read this article from The Atlantic Magazine.  It will likely affect your view on race forever.  You can’t judge a book by its cover.

Because I don't think racial labels are generally helpful, I also believe that they are a potential problem. I wouldn't want my calling a patient 'white' when they are 1/16 Native American to interfere with their self-description. This may have legal implications, perhaps for Federal contracts or programs. Will it help them or hurt one of my patients in gaining a scholarship to define their race in a certain way, especially if whatever institution looks to their physician or medical record for verification? If I don’t think I, a fairly observant physician, can tell what race you are by looking at you, I certainly don’t have confidence that—even with training—college students working for the summer can categorize your ethnogenetic heritage when they come to your door to help with the census and try to give you a careful look in the hallway outside your apartment door by the dangling blinking buzzing insufficient fluorescent light that you’ve been bugging the cheapskate landlord to fix for months.  

May 11, 2011

Back to Birth Weight

I just received a comment on a blog post.  The post was called, “Newborn Won’t Gain Weight.”  The comment from Joey, 5/17/2011, said, "What if the child is now 1 month old and still 5oz shy from birth weight? My niece is in the hospital right now. Her parents aren't the brightest and I'm worried. Thanks for writing about this by the way! " 

I'm so grateful that you have found this blog interesting. It isn't meant to give medical advice of any kind, ever.

In this true story, I was seeing the baby every few days at first, but as the inadequate weight gain continued, I was seeing the baby every single day. I was worried about the baby! It's normal for babies to lose weight for the first few days. But they should start gaining weight within about a week or so. Babies who are born bigger tend to lose more weight at first, so it might take them a little longer to regain their birth weight.

Pediatricians often use, as a rule of thumb for this initial weight loss, about 10% as a guide. If a term baby of average weight, say 7 1/2 pounds (about 3400g), loses anything less than 10%, we usually don't worry too much about it. For this average baby, that would be about 12 ounces (about 340g).

We also have a rough guide for weight gain. On average, once newborns start gaining weight, we expect them to gain about 1 ounce a day (~30g). This slows down, of course, as the months go by.

Let's do the math. If our 7 1/2 pound baby lost 10% of her weight by the time she was 5 days old, she would weigh 6 pounds, 12 ounces. She lost 12 ounces. It would be reasonable to guess that it might take 12 days (at a rate of weight-gain of 1 ounce a day) for her to regain that weight. But she only started gaining weight on her 6th day, so she'd be back to her birth weight around day 18. That's about 2 1/2 weeks old. I'm usually pretty satisfied with anything in the 2-3 week range.

Let's do it again for a bigger baby, say 9 pounds (~4100g). Weight loss of 10% would bring the baby down to about 8 pounds 1.5 ounces. If this baby gained an ounce a day, the baby wouldn't be back to its birth weight until closer to 3 weeks of age.

Babies who are born smaller, lighter, or prematurely don't have so much extra, and the 10% rule-of-thumb really doesn't apply. Remember that the baby is not just getting food but also fluid in each feeding. If there's a delay getting breast milk or formula, that's always going to be concerning.

The blog post you commented on was an example of how I manage this as a physician, in the unusual practice I have created. If a baby who wasn't gaining weight was brought to urgent care or to a doctor for the first time, it would be understandable if that doctor, alarmed by the poor weight gain, felt compelled to get some tests to make sure the baby wasn't sick in some way. It would also be reasonable to discourage breastfeeding, at least for the moment, and encourage formula use. Maybe the baby would be admitted to the hospital for intravenous fluids. None of these interventions would be wrong or bad care.

I wanted, as much as possible, to avoid these. I wanted to support and facilitate successful breastfeeding as much as possible. But the baby's health and safety are always, in every case, the most important things I care about. I have one thing that the urgent care or emergency room physician does not have: continuity. I have the power to ask the parent to bring the baby back the next day, and the day after that. I will see the baby on Saturday and Sunday and July 4th, and so on. I can give parents instructions about what to look for, and if they observe these symptoms or have new concerns, they should call me right away. When they do call, I answer the phone and I know the story, I know them, I know their baby. This concept of continuity of care is extremely valuable because I'm less likely to miss a condition that evolves over time. It saves a lot of money, because I'm not sending every child who's sick in the evening to the ER. And I'm not treating every patient for the first time. I can and do order tests and x-rays, when they're needed. I send kids to the ER sometimes.

But I can see this mother every single day, weigh the baby, try first one idea and if that doesn't work, try another. I can find out how the mother is doing emotionally and physically, how much pain she's in and how tired she is. I can find a way to get that baby on the right track.

There's a nice epilog to the story. We did feed the baby formula, but only for a few days. As the baby put on a little weight from the formula, he got a little stronger with his nursing on the breast, and was less famished when he nursed. Mom's body responded well, and they soon didn't need the formula at all. They successfully nursed for more than a year.

As I pointed out in the original post, formula isn't poison. It's an important tool we have available if we need it.