The Human Pacifier, Part 3

It would be great to have a definitive diagnosis, and know for sure why 5-month-old Andy was waking up every hour. Whatever the reason, it was torturing his mother. And that's not going be a sustainable, optimal environment for Andy.

In this case, it would be a luxury to examine every tree, but I had to see the whole forest, and it was on fire. Sure, the care that most families would get probably wouldn't include trying to fix these problems, and probably wouldn't include even looking for these problems. It just takes too much time. But that's not who I am and not how I practice. And it's not the best thing for the patient.

So I decided not to try the many possible interventions in series, one after another, in a way that would eventually yield a diagnosis and medical approach to the problem. This family needed my help right away, and they couldn't wait around, trying one thing or another just so I could claim a diagnosis. I explained this to them, and they seemed relieved. I suggested doing everything at once. Hopefully, something will work. Once the problem is fixed, we could, if desired, peel back the interventions layer by layer as if an onion. Perhaps in this way, we could arise at some diagnostic insight but not wake up the sleeping baby.

First, let's establish a transition object. The transition is a fairly nonspecific one—perhaps between wake and sleep, or from being held by mommy to not being held by mommy, or maybe between a sense of security and insecurity. Sometimes it's called a security blanket. The most well known, perhaps, is that of Linus, created by Charles Schultz. I suggested that the parents get a baby blanket like those used in the hospital nursery: soft flannel, but nothing fancy, hand-knit, family-heirloom, or large. A hand-towel or even a washcloth will do. Every time the mother nurses the baby, she needs to hold this between the baby's body and her own. It will pick up her scent, breast milk, sweat, and the baby's drool, spit-up, and scent. This too, has been studied. Even babies just a few weeks old can recognize the scent of their own mothers. Whenever the baby is being put to sleep, even if in a parent's arms, the cloth has to be there. Maybe, at those shallow levels of sleep, the sensory feedback gently provided by this transition object will be just the reassurance necessary to send him back to a deeper level of sleep.

I told them to bite the bullet and put the baby in the other room. Yes, get rid of the co-sleeper. Every time the baby is getting to a shallow sleep level, he smells fresh muffins and needs his mother to provide them. I want her to be available to comfort him if needed (this is NOT about crying-it-out), but I want him to work a little harder for it. If you are just barely awake and smell the fresh muffins baking, vs. just barely awake but have to get dressed and drive to the muffin shop. Either way, you get your muffins. But I bet you sleep a little longer if you have to go to the store. I expect that changing his pattern of sleep/wake will not be easy at first. I didn't suggest letting him go cold turkey on this. That's what the transition object is for. How much worse can it get?

The removal of the infant into the other room, I hope, will enable mother to miss some of those subtle vocal cues that she has been conditioned to hear and cause her awakening. Maybe if she's not hearing the baby talk in his sleep, she won't have to wake up unless he really wakes up. And both she and the baby know that he's not really eating all through the night. The nursing for 1-2 minutes is not long enough for a nutritive meal. It's for brief comfort.

The baby's eczema must be treated. I prescribed some lotion with a very weak steroid in it to use on the dry patches and on the dry patch on his scalp. Hopefully, this will relieve the baby's itch and let him sleep better and longer.

If the baby has heartburn, which seems consistent with some observations of the parents, he's not going to like being put down flat, and he'll be harder to comfort and may not sleep as well. We know he seems to sleep better in the swing than in his crib. Why not let him sleep in the swing? I also suggested they let him sleep in the car seat. This will keep him in a much more upright posture (adults with heartburn often sleep with a lot of pillows or with the head of their bed propped up) and keeps him securely snug. I cautioned them not to put the car seat on a table, bed, or any other surface. If they put him to sleep in one, it needs to be on the floor. Even gentle movement of the baby can cause most car seats to move across a surface and fall to the floor.

And if this is reflux, why not treat it? I prescribed some first-line antacid medication. I don't like putting babies or anyone else on medication, but sometimes you have to keep your eyes on the prize, which is helping the baby feel comfortable enough to sleep through the night. My job is not to minimize medication. My job is to make the baby's life better.

I had an assignment for dad, too. I told him that life is tough all over, and he was going to have to pitch in. I wanted him to take the middle-of-the-night feeding if there was one. If not, he would have to take the first feeding of the morning. The baby might indeed get hungry in the wee hours with the new regimen of comforting the baby without nursing every hour. Mom has plenty of pumped milk and the baby will take a bottle. So dad is going to get the big feeding while mom is going to get what I hoped would be at least 4 hours of uninterrupted sleep.

Lastly, they needed to establish a rock-solid bedtime routine. Doctors who treat insomnia note that the overwhelming majority of their adult patients have poor sleep hygiene. That means that they have the TV on, that sometimes they go to bet at 10, sometimes at 2. Maybe they sometimes eat before bed, sometimes not. People of every age respond to the ritualization of sleep, and the establishment of sleep cues. I suggested that every night at their chosen baby bedtime, they have the exact same routine. It might start with turning off most of the lights, then giving the baby a bath. Then they put on a fresh diaper, mother sings him a song while nursing, then more lights go off, then he is put in the crib in the other room (or the swing/car seat as above). With his transition object.

They're coming back in a few weeks. I don't know what has been working or not. When I do, I will post Part 4.

The Human Pacifier, Part 2

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

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

I made my choices of how to approach the problem based on how I see my role, by my experience, and by who I am and the kind of doctor I want to be. In my career, I have worked with many other doctors and I know what most of them and all of the insurance companies would have me do:

• The baby is my patient.
• The baby is OK, healthy and developing normally.
• Establish the health status of the baby, give the parents a handout (called, perhaps ironically, 'anticipatory guidance') and make an appointment for the next well-baby visit.
  
  

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

My visit: 124 minutes. What was I doing? Mostly, I was listening to the mother and father. Here's what I learned from listening, that others might have missed.

1. The baby would shake his head violently when placed on the crib. No, that's not normal. A very careful exam of the child's head showed a pink, flaky area on the back of the baby's head. Cradle cap? Ringworm? (The baby's awful young for ringworm.) In the course of the long visit, while talking to the parents, I was making faces at the baby and watching his response. Smiling. Laughing. Scratching. Sure enough, the baby was sometimes scratching his head, his thighs, his stomach—pretty much wherever he could reach. So I didn't just look in his ears and listen to his heart. I gently ran my hands over his skin, and the sandpaper-like patches were obvious to the touch, but invisible to the eye. I don't know if the little patch on his head was pink because of the head thrashing, but I knew the baby had eczema. Studies clearly show that babies who are itchy (and adults too, by the way) don't sleep well. They don't sleep as deeply and awaken more easily and more often.
   
   
2. The baby didn't like to be horizontal. He didn't spit up much more than usual, but he was spitting up after nearly every feeding. He seemed to sleep better when propped up in the swing, even if the swing wasn't going. Though every baby is born with gastroesophageal reflux, some of them show remarkable and rapid improvement in their irritability, sleep patterns, and willingness to be placed on their backs following basic anti-reflux positioning and medications.
   
   
3. In the Pavlovian world of conditioning, who got to play Pavlov's Dog—the baby or the mother? Here' my interpretation of what was happening in the bedroom, where mother slept in the bed attached to the co-sleeper where the baby slept, while dad slept in the other room. As in the analysis of any two-part system, let's look at each component.
   
   
   
   1. The baby. Have you ever slept in a place (maybe grandma's house, maybe sleeping over at a friend's house) where somebody woke up early to bake fresh muffins in the morning? OK, maybe it was bacon frying in the morning before you were up. I'll come back to this in a moment. First, my view on the baby's sleep. Here's what happens. We cycle through various stages of sleep. In stage 1 sleep, we're just barely asleep; in stage 4, we are not moving, breathing slow and deep. In Rapid Eye Movement [REM] sleep, we talk in our sleep, move around a lot, and dream. I suspect that in the baby's REM sleep stage, he's vocalizing just as he did with me in the office. It's not crying, just making vocal sounds. In this stage of sleep, he's also moving around. Whether he's dreaming of breasts is anybody's guess. But he makes some sound, that mother is pre-emptively reacting to. Even if this is just a stage of sleep from which he will descend without help into a deeper and quieter stage. But mother picks him up and...fresh muffins! Now, not only does he have an incentive to jump out of bed and check out whatever delicious goings-on are happening in the kitchen, he is rewarded for doing so by the positive feedback of mother's touch and nursing.
      
      
   2. The mother. Anyone who's ever used an alarm clock to get them up for school or work knows that the alarm clock makes itself superfluous. For a few days, maybe a few weeks, on the same schedule, the alarm clock wakes us up. Sometimes groggy, we force ourselves out of bed and off to work. Even if we go to sleep way too late the night before, we still wake up moments before the alarm goes off. What's happening is that our brains have been conditioned in ways that I don't think are fully understood. Somehow we are programmed to awaken at a certain time every day. For new parents, they—or sometimes just mom—get so sensitized to the sounds from the baby or baby monitor that they hear these sounds even in a crowd or over the sound of a TV. The baby is smelling fresh muffins when he's not awake, but in a shallow-enough sleep stage to pull himself to wakefulness. Mom has been conditioned to anticipate the alarm before it goes off, and never lets herself get to a deep enough sleep stage for effective rest. She is also conditioned to awaken at the first sounds that come from the baby, whether or not they are a request for her services.
      
      
   3. The pair. This coupled system could, in a previous life, have induced me to attempt to model and analyze it. Suffice it to say that the baby does what comes naturally, with a spiral of positive feedback. The mother does what comes naturally, from the love for her baby and the willingness to sacrifice. But it's a dysfunctional system, in which the unsustainability of prolonged sleep deprivation of the mother will not have good or even benign consequences for the baby. Aha! The baby is my patient.
      
      
   
   
   

4. The problem of mother's lack-of-sleep, and dad sleeping in the other room, is a problem for the baby and needs to be fixed, if possible.
   
   
5. What difference would a diagnosis make? The baby was not in medical danger from some unidentified disease. I just needed to get this mom through the night.
   
   

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

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


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