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.

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.

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?






Technorati Tags: infants,pediatrics,diarrhea,childhood illnesses,child development

Vaccine Refusal and Ethical Issues

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

The Empathic Family Meal

In the last post, I’ve pointed out that a family meal is a good idea.  At least by current research, there seems to be solid evidence that family meals are good things for your kids.  When read critically, the research leaves many questions unanswered.  Research shows that kids who eat regular family meals have lower rates of obesity.  And lower rates of other problems.  It could be that kids are less likely to have eating issues if they come from these cartoonishly-structured families. You know, the families where mom is in an apron most of the day at home and dad comes home from work about 5:30.  It could also be that families that make an effort to get together and keep in touch with the lives of each family member are more supportive, and this is a key factor in prevention of obesity.  Maybe just the fact of having a dependable dinner every night prevents that fast-food or pizza stop on the way home from school. 

Since I’m writing this to encourage you to make a family meal part of your daily routine, or part of your weekly routine if you can’t do it daily, you should have an idea what an Empathic Family Meal might look like.

Those that follow my general take on parenting see that I encourage an empathic approach.  The authoritarian, Top-Down Management model of parenting—as would be practiced by the family I described above with mom at home wearing an apron and so looking forward to the time her husband will give her permission to leave the bunker and freshen up their survivalist hoard—is not going to get a lot of support here.  But because these families don’t move much (it’s just so inconvenient to pack up all the firearms), have stable family structures and menus that are easy to keep track of, they are heavily followed by researchers.  That alone might skew some of the conclusions.

It’s both funny and foolish to look back on those family meals from our own childhoods or those we have witnessed.  Sometimes they were opportunities for bitter parents to enforce conformity, where having an elbow on the table was an offense deserving of discipline.  Children were there to be interrogated about their school or personal lives, and their attempts to keep certain parts of their lives private were never respected.  Occasionally, parents who were either sadistic or indifferent would bring up the most humiliating issues at the dinner table.  You know this is possible.  It has happened to you or your friends.  (These parents are the ones who in 30 years will have adult children that don’t talk to them.)  So there’s a danger in the power structure of the family meal that I think has been ignored.  Absolute power, corrupting as it does, has a nasty tendency to make the people sitting at the head of the table really believe that they are in charge.  Like a president-for-life in a small ex-colonial country, they really believe that if they are happy, the family is happy.

Family meals do more than somehow help reduce the chances of obesity and eating disorders.  They are a great way of reducing picky eating in younger kids, and getting children to try new--occasionally even green--things.  This can be accomplished with an empathic family meal. 

Here is the best way I know to get a preschooler to eat vegetables.  Give them some guidelines, take them to the market, and leave them in charge.  Start with a plan.  Maybe your plan is that on Wednesday night, Eric is making dinner.  Why would he?  Is this just another unrewarded chore that Eric, 5, is supposed to do while you catch up on your emails?  Of course not.  Eric’s true reward is the one-on-one time he will spend with you.  First, you and he will plan a menu.  Make the menu suitable for a weeknight family dinner.  There are many fine cookbooks with short recipes, if you don’t know some off the top of your head.  This dinner, however, does not consist of a phone number and stained paper menu of the ethnic restaurant that delivers.  From the menu, make a shopping list.  From the shopping list, make a trip to the market.  With Eric.  This last part is crucial for success.  When you call your partner to pick up some broccoli on the way home, you have rescinded Eric’s ownership of the event.  He needs to pick it out.  However ridiculous it may appear, he makes an important step when he’s at the market with you and picks out one bunch of broccoli over another.  In his mind, he has been given authority over what his family will eat.  You have trusted him with your sustenance and he has taken up that challenge. 

I often encourage new parents to put aside one bottle a day for dad to feed the baby.  A baby bottle, I mean.  Whatever bottle dad was hoping for is his own business.  However sleep-deprived he might be, that intimate time with the baby, giving her what she needs, is profoundly meaningful to new dads.  Even though newborns may not smile or laugh, the dads have no problem sensing their baby’s gratitude.  It’s a moving and wonderful thing that every mother knows.

I think this wonderful generosity of supporting another’s life through food stars with feeding a baby.  It continues through life.  There’s a reason humans of all cultures socialize over food.

So picture the parent I saw today with an 18-month old.  She complained that he’s “starting to get picky about eating.”  She said that she fed him in the kitchen before she and his dad sat down to eat.  I asked why they didn’t have him at the table with them.  She said that it was just too much trouble because he would keep grabbing their food if they held him, and if he was in his high chair, he would complain about not getting stuff off their plates.  Do you see the empathic parenting lesson here?  When they give him baby food he’s not interested in, he won’t eat it unless he’s very hungry or it’s one of his favorite foods.  We’ve all had this experience.  We look in the full refrigerator, the bursting pantry and complain that there’s nothing to eat.  That’s us.  We’re picky, too. 

But we usually will eat if the company is good, and even if the food isn’t just to our taste, we’ll be polite about it because we see how happy it makes others.  Babies know this and they feel it.  This 18-month-old was telling his mother this in the clearest way he could.  Isolating the child isn’t what he wants.  If he had a place at the table, it would indeed be a lot messier.  But he would love to taste the broccoli off mom’s plate and maybe some of the clam chowder dad was eating.  They don’t want to try healthy foods, and they don’t want to try new foods.  They want to try your foods.  Let them.

Empathic Grandparenting

As I publish more and more about parenting, I’ve been getting a lot more questions about the role of grandparents. Parents, whether biological or foster or adoptive or step or any other kind, have certain reasonably uniform tasks they usually need to accomplish with their children. Survival basics, such as food and shelter, schooling, love and support, and promotion of the child’s general sense of growth and accomplishment as they grow and develop. If there are some hurdles on the way, people ask me about it, and I do my best to give them some ideas on how to manage.

When grandparents are the primary caregivers for the children, and there are many, many families like this, then they are really acting as parents. In this context, parenting advice applies no matter what your title is. I have known fine adults raised by relatives both close and distant, and sometimes by parents who weren’t related to them at all. In all of these situations, I recommend openness about the reasons behind the situation. This openness should be limited to what is developmentally-appropriate for the child, and which protects the child’s sense of self worth. If parents are gone, then they’re gone and there’s no point in giving the child further opportunity for emotional scars by learning that what you say can’t be trusted. It’s hard to imagine a sadder image than a child waiting at the window for the parent who won’t return. So be as honest as you can with them.

An important part of the bargain when we take on the responsibility of being parents is that there are no warranty periods or lease expirations, during which we can trade up to a new model as long as the one we’re returning has only normal wear-and-tear. More needs to be said about what is and is not appropriate, and I’ll try to do that another time.

For most grandparents, however, the primary responsibilities of care for the grandkids falls squarely on the shoulders of your children and their spouses. This is a blissful arrangement in which you get most of the benefits of child indulgence with little of the consequences. Sure, it’s not as good to buy love as it is to get it spontaneously. But--just between us--it’s still love and it feels mighty good when bartered for some new toy or ice-cream before dinner that mommy would throw a fit about but we’ll just keep it as our little secret.

For those who’ve been reading my advice about getting kids to eat right and behave nicely, it might come as a surprise to know that I don’t disapprove of any of the above. Every child deserves to have somebody in this grandparent role, where some of the rules are a little more flexible than at home. I think there’s an important place in every child’s life for a trusted non-parental adult who isn’t spending every waking hour managing the relationship. But that’s not the same as having carte blanche.

With that said, however, we all know that childhood obesity is a big problem. There are many causes, of course, and I have no special cure or treatment. But I have had one insight that I have not seen written about in all the studies I’ve read: grandparents.

There are many reasons that both parents have to work outside the home. Mine did. With most elementary schools still dismissing their students at 3:00 in the afternoon, most working parents have to find some arrangement for the 2-3 hours or more before they get home from work. In my community, this is often a job gladly taken by grandparents. They treasure the opportunity to be with their grandchildren and have such an important role in their lives. They also are happy to help their children by being there when needed.

But when I talk to children who are overweight, I ask them about their diets. It becomes clear that their parents aren’t usually taking them out for fast food, and aren’t letting them eat potato chips instead of dinner. Most parents are reasonably careful about what they feed the kids, so the extra calories aren’t coming on their watch. Again and again, the calories just don’t add up. While it’s true that school lunch is often not nutritionally optimal, it’s usually not a major problem. They usually don’t have the money or transportation to get fast food. But again and again, I hear about the time in the afternoon with grandparents. There’s a lot of school-day afternoons filled with television and very fattening snacks. It’s one thing to be the indulgent grandparent who gets the kids stuff their parents wouldn’t or couldn’t get them. It’s quite another to be contributing to serious and long-lasting health problems for the child. Though I don’t want to be confrontational, I really wonder if these grandparents, who melt at the first hint of a whine, really feel all right with the consequences of that big piece of cake as an after-school snack.

I have often wondered about the mysterious mechanism by which brain functioning seems to change as soon as one’s offspring has offspring of their own. There is a clear difference between being a grandparent and being a parent, and I’m fine with that. But why, besides failing vision, can’t grandparents see that their grandchildren don’t need that extra cookie?

We get our parenting knowledge from several sources. Our own experience as a child is a major source, whether this was good or not. Our perspective on the parenting techniques used by our parents is a very biased one. In general, we love our parents. Perhaps as a result, I have heard people describe as useful some incredibly counterproductive experiences they had as children. Did washing your mouth out with soap stop you from using bad language? Sometime, parents are aware of the mistakes made by their own families, and make a conscious decision to go in another direction. This leaves the parent trying to find a path when they have no landmarks. And, of course, there are all kinds of parenting experts willing to suggest things, perhaps in a book or blog, that the parent hadn’t thought of.

Grandparents, however, have the certainty of their own experience. This can be a pain in the neck for parents who have decided to do some things differently. Just because you raised your kids a certain way, doesn’t mean that’s the only right way to raise them. This is often a major source of friction between adult children and their parents. If you, as a grandparent, value contact with your children and grandchildren, you must respect their point of view.

I guess it should go without saying that there are always exceptions. But it’s a mistake to assume that you are one of these exceptions.

In the next post, I’ll offer some specific guidelines for grandparents.

The Human Rickshaw

As babies get to the second-half of their first year (around 6 months onward), most will no longer need to feed several times during the night. Their stomachs are generally big enough to hold enough to keep them more or less through the night. The stomach of a newborn can only hold an ounce or two, and few foods are as quickly absorbed and digested as breast milk. So even after a good nursing session, the newborn baby is often hungry again in a couple of hours. They awaken hungry and should, of course, be fed all they want.

But these older babies have also experienced the miracle of positive feedback: when they were younger and cried, mommy miraculously fed them and held them close, spoke to them and comforted them. So even though the need for nutrition during the night is decreased or eliminated, the power of those comforting sensations is as great as ever. So The Human Pacify-ee did improve, but he didn’t extinguish his frequent awakenings through the night, every couple of hours or so.

When the Pacifier recently returned to the office with him, I assumed it was for the same problem. I asked her if she had followed some of my suggestions. She said she did some but not others. She thought his frequent awakenings had improved a lot, but she just couldn’t take the last couple of steps. ’It’s not a problem for me,’ she kept on saying.. She had to choose a spot she felt comfortable with, of course. But I would not let her say it doesn’t work if she gives up on it. And though she might be able to tolerate this at this age, how will it be when the child is 3 and she’s back in my office complaining that the child is coming into her bedroom and bed every night and preventing her from getting any sleep.

I told her that it was OK with me, of course, for her to choose what she is and is not comfortable with doing.

Baby walkers were a big hit several years ago. Babies adore them, so parents are enthusiastic too. Gradually, however, Emergency Rooms across the country started to see the injuries they caused, some of them really serious. A walker gives a baby who can’t walk the ability to move themselves wherever they want to go.

But they don’t see obstructions or problems ahead of their path. The really bad injuries tended to be of two types. 1. Stairs. Once the walker rolled over that top step, it would tumble. Once the walker tips over, the baby’s body and legs are protected, and the full impact lands on the most exposed part of the baby: the head. 2. Pulldown. As every puppy knows, there’s a lot of interesting and delicious things on tabletops that they just can't see. The baby who can’t walk now has the walker to get them over to the side of the table or the side of the stove or ironing board. The walker keeps them upright in a position they are not developmentally capable of doing on their own. With both of these new capabilities, they can finally indulge their curiosity to see what happens when they pull on the handle of that brightly-colored pot on the stove they are standing right next to.

Babies are genuine explorers. They want to see the edge of the world, perhaps just around the corner. So, since The Human Pacifier was told in no uncertain terms by me that there would be no walker in their house, she finds herself metamorphosed, like a reluctant chrysalis, into The Human Rickshaw. When I pointed this out to her, she pointed out that this was a particularly luxurious rickshaw: it served only one customer, and had The Human Pacifier on-call at all times to meet the whims of its master.

The Human Rickshaw explained to me that she knew she was summoned by a brief grunting cry and a quick movement of two arms thrust vertically into the air, as if clearing up any ambiguity about a contested goal. If not picked up within the appropriate pickup-time window, the rickshaw passenger lodges a formal complaint to management. When I pointed out this pattern to The Rickshaw, of which she had been wholly unaware, she said she wasn’t worried about it because, ‘It’s not a problem for me.’ Though happy that it was not a problem for her, I probed further into the everyday activities at home. It turns out that this PhD scientist had swapped roles with the subject of the experiment.

In responding to my frequent suggestion that parents be the grown-up, there are several definitions of adulthood. This baby wasn’t paying the rent, buying the food, changing his own diapers. But he was firmly calling the shots with mommy in most important ways--the ways that affected mommy’s life in a problematic way.

This is not naughty behavior! There is no discipline, no punishment, no consequences that should ever be used in a baby this age. Though his behavior is inconvenient, perhaps a pain in the neck, where did he learn it? How did he choose it?

For all children who are no longer newborns, there is only one Holy Grail, only one irresistible drug. That is a parent’s attention. They will experiment with every kind of behavior that comes to mind. Sometimes this includes biting, hitting, pinching, screaming in ways that, if continued, could cripple our domestic glass-making industry. This child was a prodigy at this developmentally-normal task. But he needed an adult as his mother. Someone who could turn away instead of dutifully lowering the arms of the rickshaw yet again, and silently hoping that the baby’s destination would leave her somewhere near the office of the backache clinic.

Solids

Of the approximately 100 members of my class at Yale School of Medicine, every single graduate—100%—were eating solid food.

With that admittedly anecdotal experience, I have reassured many parents that at some unpredictable point between 4 months of age and medical school, their baby will—I virtually guarantee it—eat solid food.

Jamie, barely 4 months, used to sleep 6 or even 8 hours at night last month.  But as the weeks went by, he was awakening more often.  His parents said that he’d get a good nursing at about 10pm and then he’d be out for about 3-4 hours.  Then when he awoke, he’d nurse again, out for 2 hours.  Then 1 hour intervals through the rest of the night.  The nursing was sometimes 15 minutes, sometimes 30.  What was happening?

Unlike The Human Pacifier, this 4-month old appeared to want to eat.  He wasn’t looking for reassurance or comfort during the night, he was really nursing.  There’s a behavioral aspect to frequent awakenings, that can become a problem as babies get older.  (I hasten to add that there’s no crying baby who doesn’t need attention and care.  Maybe there’s a sleep problem or a behavioral issue, but the approach to this should never include ignoring the baby, even if it does include a measured response.)

There’s no way to untangle the comfort provided by nursing with mommy in the middle of the night from the baby’s hunger.  Or is there?  In the 3-part Human Pacifier series [part 1, part 2, part 3], the baby was waking up to nurse for a minute or two, sometimes less.  He’d go to sleep right away after just a moment or two of snuggling with mom.  But Jamie’s mom didn’t have it any easier.  She, too, was getting up nearly through the night.  This baby was nursing pretty much to the capacity of the mother’s production.

Here’s what’s going on.  The baby is full when he’s going to sleep.  That’s why he has his longest sleep immediately after that last big feeding.  He was about 2 pounds less a month ago—that’s a big proportion of his body weight.  At the time, it was enough to keep him nearly through the night.  Now, it’s enough for 3 hours, maybe 4.  Then he wakes up hungry.  Nursing for 15 to 30 minutes is enough to take the edge off his hunger, and get him back to sleep.  It’s not enough to fill him.  The less-than-enough feeding may take the edge off, but it’s not enough to last long.  So this second feeding doesn’t last as long as the first.  He wakes up and mom does her best.  But 2 hours later, he doesn’t get the same amount he got after giving mom a 4-hour break.  Her manufacturing apparatus just isn’t set up for just-in-time inventory management.  He’ll get just enough to take the edge off again, but this time wakes up in an hour.  This is much less time than the factory needs to meet demand.  So from this feeding until morning, both baby and mother are locked in lactational Reaganomics—a trickle-down model of infant feeding.

So there’s a couple of logical approaches, with both possibly rooted in an econometric, perhaps even game theory perspective on infant rearing.  Isn’t this the approach most parenting authorities take?

First, we can decrease demand to match supply.  It’s hard to see Superman taking valuable time from his busy schedule and presumably many other commitments to fly really fast around the planet backwards and so turn back time to when the baby would stay full through the night.  There’s some ambiguity about how Superman ages, since he progressed from baby to newspaperman quickly but hasn’t changed much since the 1950’s.  I mention this because he’s going to have to accomplish this same task every month forever if we’re really intent about restraining the baby’s growing demand.


So, like true Reaganomics devotees, we need to focus on the supply side.  Here, there is a fork in the road.   There are many ways to try to increase milk supply.  This is a reasonable way to go, for a while.  Babies, however, can be relentless in their ever-increasing demands.  Will they never learn?  The other fork bypasses this captive supply chain and outsources the inventory management.  This baby was ready for solid food.

Human milk is really easy to digest.  There isn’t much else that goes through a baby’s stomach faster.  Solids get digested much slower, so they keep the baby full a lot longer.  For the record, the calorie content of solids is typically much less than breast milk or formula—so I don’t rush to start solids in babies who are having problems gaining weight.  Not every baby takes to solids right away, but the level of stress this induces occasionally confounds me.  I think of my fellow graduates and can’t think of a single one, not one, who wasn’t eating solid food.  I can’t authoritatively say that this was true at other medical schools, of course.

Rule #6: Dr. Wolffe's 'Baby' Rule

First, an editorial note. I don't know if this is really rule #6. I think if I had called it rule #1 then it would seem to be the most important rule out of however-many rules there turn out to be. Rule #2 will have you wondering what is the rule that is so much more important than that. Rule #79 seems more like a guideline than a rule. I will post other rules as they arise, and will have to see where their numbers unfold.

6.  Dr. Wolffe's Baby Rule:  
Never apply any product to your baby that has “Baby” in the name.

Simple, right? Hospitals often give out free samples of products covered under Rule 6.  Feel free to use them on yourself. Don't start with that blame-the-drug-companies stuff, either. Pushed equally hard, and at considerably higher prices, are many product lines of 'natural' products targeted for use on babies. Are these products natural? In fact, they are designed to be marketed to parents who really want to use all the products covered under Rule 6, but who feel better about themselves by buying the products in a purportedly greener venue. I'll go through the usual suspects:

1. 
   Baby Shampoo. If your baby has any hair at all, how dirty does it get? Dreadlocks—I don't think so. Dripping with sweat from being overambitious on the stair-climber in the gym after work? Not likely. If your baby has cradle cap, especially if it's severe cradle cap, the baby might need a prescription shampoo. Baby shampoo won't help it.
   
   
2. 
   Baby Wash/Soap. You know that car that's jacked up on concrete blocks and wire milk crates in your front yard? The one that your neighbor applied for a court order to have you remove because it was bringing down property values? Let's say you're under that car replacing the starter motor that burned out when you let that dim cousin Dale (though everyone calls him LD which stands for 'Little Dale' because everyone calls his father Dale) use the car briefly in 1997 and he ground at least two teeth off the starter ring gear.  You're being a conscientious parent,
   
   
   
   
   watching the baby, who you have next to you on the wheeled creeper under the car. Loosening the transmission fluid cooling lines sends a gush of dirty transmission oil all over the baby. Now you're going to need some soap when you bathe the kid. Until that happens, however, nearly everything else that gets on the baby will come off with plain water and gentle wiping with your bare hand.
   
   
   
   
   
   
3. 
   Baby Oil. What is this stuff, anyway? How exactly are babies industrially processed to extract their oil? Is it refined? Crude? Extra virgin? It turns out to be mineral oil, refined from petroleum, plus fragrance. Your baby needs fragrance? If your baby smells unpleasant, that's a signal for you to be taking some sort of definitive action to remediate that issue.
   
   
4. 
   Baby Lotion. There's an old-fashioned expression: smooth as a baby's behind. How did it get that way? Not from lotion, I assure you. There are babies who have dry or problem skin. It's hard to imagine that a baby with very dry and sensitive skin is somehow going to be helped by a mix of heavily-fragranced, colored, saponified organic compounds. If you buy the 'natural' brand, it will probably also have calendula in it, which can really do some damage to sensitive skin. (See my post on this topic.) On a related note, the peeling skin of a newborn has nothing to do with the skin being dry. Everybody's skin would peel after a 9-month bath.
   
   
5. 
   Baby Powder. Powder is by definition dry, so is indeed a logical choice for absorbing liquids. Will it keep the baby dry? Do this yourself—put some in your hand and see what happens when you add a little liquid. Does it absorb much? Or does it turn into a strongly-smelling congealed abrasive? And what, exactly, happens to that cloud of particulates that seem to linger in the air that you and the baby are inhaling?
   

If this has left you feeling like you have to throw away your entire shopping list, don’t despair.  Here’s a Baby product to put on the list.

And there’s always this.

A Glimpse of New Autism Research

Over the years, I have acquired many autistic patients.  The community of parents is relatively involved in groups of one kind or another, and useful resources are generously shared.  Once they come to me, the parents are generally happy with the service I provide.  Because I take my time and am very careful in establishing some kind of rapport with the child, the kids seem to like me and as a result will allow me to examine them.  The parents, I think, appreciate my very slow approach and willingness to let the child have some sense of control in the exam room—which is often stressful for the non-autistic.

I was lucky to have once taken a course given by Fred Volkmar, and have attended many scientific talks by him.  He and colleague Ami Klin are, in my professional opinion, the people who know more about autism and autistic spectrum disorders than anyone else on the planet.  (Over in my Amazon store, I have put some of the key books that they have written about Autistic-Spectrum Disorders in the section called ‘The Autistic Spectrum.’)  Several years ago, I attended a talk by Volkmar at which he showed video of groundbreaking experiments with autistic people.

They would be shown a clip from a movie.  If I remember correctly, it was a scene from Who’s Afraid of Virginia Woolf?  The movie is heavy on dialog and interpersonal drama, but not too much action.  Subjects in the study were rigged with a camera that tracked the movements of their eyes and mapped that to the screen.  In this way, the experimenter could see and keep track of exactly what the person was looking at on the screen.  Even if the people on the screen were screaming at each other, if you were looking at the sofa, this apparatus would pick it up.

Why did they even try this elaborate experiment?

Though they never discussed it with me, it probably has its roots in the problems people on the autistic spectrum have with social interactions.  Even when their language and intellect is fine, eye contact can be awkward or avoidant.

What they found was that typically-developing subjects would follow the drama by watching the actor’s eyes, and change the eyes they looked at when the speaker changed.  Those on the spectrum kept looking at the actors’ mouths.  As the scene unfolded, this pattern became more and more clear.

Jump forward maybe 5 years or so to today, when I found a recent research study by Klin and others in Archives of General Psychiatry.  Now they used the same kind of apparatus, but had 2-year-old subjects.  They spared the kids all the friction between Elizabeth Taylor and Richard Burton by producing their own carefully-orchestrated movie of a friendly grown-up talking and singing and playing games with them onscreen (like pat-a-cake).

The eyes of the children followed remarkably different paths.  The ASD children looked at mouths.  The typical children looked at eyes.  Even a group of developmentally-delayed children looked at eyes.  The more severely autistic the child, the more they seemed to prefer mouth over eyes.

Wait—is it the mouth that’s so interesting or is it just because it’s moving?  So in another experiment, they showed just an animated outline of the actor, both upright—which you might be able to figure out—and upside-down, which looks nearly uninterpretable.  The experiment was run again with an animation that showed movement coupled with sound, which they called ‘audiovisual synchrony.’  This proved to be the most attractive of all.

Why is this so important?

There are two big reasons that come to mind right away.  First, there is no test for autism.  There’s no lab test, nothing.  With some basic technological standardization, this apparatus and its interpretative software could be an essential tool not just to identify affected children but also to measure how affected they are.  That’s been a dream of those working in the field for a long time.  Often, kids were given the diagnosis because they weren’t speaking, even though their social interactions were generally OK.  Sometimes those with real trouble with their social interactions would not get that extra coaching they need because their language was normal (Dr. Volkmar, by the way, literally wrote the book on Asperger’s Syndrome).  An autism diagnosis was usually dependent on the examiner.  An objective test of any sort would help to figure out if there really is a growing incidence of autism.  And it would enable all of us to figure out if an intervention were actually helping.

But there’s another big reason, though the authors of the study barely hint at it (rightly so, since they didn’t study this).  Research on babies over the past 100 years or so has shown that babies—even newborns—prefer the sight of a human face.  The faces we make when we hold and play with a baby are thought to be essential for both normal brain development and normal development of attachment and social interaction.  What if they show that this aberrant gaze issue is present in infants that eventually have an ASD?  It’s a great thing because kids won’t get diagnosed at 2 or 3 or 4.  Early intervention has a chance, at least, of having a substantial beneficial impact.

And there’s my hidden agenda….  If we hook a 1-month-old up to this camera and show this animation, and the baby is diagnosed with autism, what does that imply—once and for all—about MMR vaccine, which kids don’t get until they’re 12-months old?

Addendum:  I found another interesting research study, though it’s a little heavier in the molecular biology.  This study found that some common genetic variants, all on Chromosome 5, correlated with autistic-spectrum-disorders.  I’m hoping that  this results in prenatal testing.  And then maybe a few more children will get the shots they need.