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This blog has moved to www.drwolffe.com. 

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?'

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. 

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.

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.

 [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.  

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.

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. No, 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.

Hothouse, Postpartum—Part 2

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.

Hothouse, Postpartum—Part 1

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.

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.

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.

Boob Job—Breastfeeding in the Real World

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.

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? 

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.

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, 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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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.  


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.