Monsters: Part 3

The Monster Whisperer

In Monsters:  Part 2, my medical colleague, a very smart adult physician whose office is across the hall from mine, burst in and asked for a urgent medical consultation, assuming I had expertise beyond his own.  He asked me what he can tell his distraught patient to help her get rid of her child's witches.

I didn’t think her child was afraid of the fact that there are witches. She’s not afraid of their power to do things by magic.  She’s not afraid of their malicious motives or the scary way they look or dress or of their scary henchpeople or flying monkeys.  I thought that gentle questioning of the child, while never doubting her belief in witches, would probably reveal that she’s afraid they will come into her room when she’s asleep, and work their bad intentions there.  (I would use this opportunity to point out that it is the child’s concrete thinking that doesn’t usually consider that a witch with magic powers could cast an evil spell from afar, without warning.  In Snow White, why couldn't the evil queen just wave a wand over in her palace, and do her mischief from there?  Despite her apparent powers, she had to get Snow White to take a physical bite of a tangible apple.)  As in Monsters:  Part 1, with the child so afraid of a toilet monster, this child was keenly aware of when she was most corporeally vulnerable.

How can we help?  If we tell them that their belief system is sheer nonsense, we alienate them and make them feel worse.  If we sympathize with them and agree that witches are a constant threat, they might continue to trust us, yet their fear is reinforced and we have confirmed that there is a dangerous broomstick-riding predator somewhere above us just waiting for the right opportunity to strike.  Keep watching the skies!

Our problem is that the child's fear is magical, but we are limited by our physical reality.  Or are we?

• If her specific fear is of a witch entering her room, she might benefit from a meticulous bedtime ritual of closing and locking her windows at bedtime.  If it’s hot and her window must stay open, how about getting a special witch screen that fits the opening?  The openings in a window screen are very small and no witch could fit through.  Or maybe witches can’t fit through those window safety bars that you are going to install to protect your child. (Maybe you should be doing that anyway.)

• Consider a special witch treatment or repellent that is not toxic once dry but is especially specific and new to the child.  My favorite for witches and related hazards is witch hazel, a pre-19th-century remedy for many things with a distinctive smell.  Because it is not in widespread use these days, it might not be easy to find.  But it sounds like a logical product.  So an exhaustive hunt for it with the child in tow will have that much more of a chance of effective pest extermination.  As you go from pharmacy to pharmacy, don’t look on the shelf!  Since the child can’t read, it is not helpful when you tell her that you looked and there’s no witch hazel there.  How can the child be confident of that?  Make a point of asking a manager—always with the child right there—if they carry witch hazel and if not, where you might be able to get it.   Maybe it can be used to seal the joints around the windows and doors.

These aren’t tricks.  I will repeat that lying to your child is never, ever a good idea.  Are these lies?  Is my approach dishonest?  Yes, in spirit it is dishonest, because you don’t, in fact, believe in witches or in the monster du jour.  But these anxieties and beliefs are a normal developmental phase.  I often discuss concrete thinking and the ways a parent has to anticipate and deal with a concrete thinker.  I have also discussed in previous posts the gradual development of abstract thinking as a mark of adulthood.  The kind of thinking that gives rise to this kind of childhood anxiety is called magical thinking.

With magical thinking, there does need to be some sort of a link between observations or events, but it doesn’t have to be rational from the point of view of an adult.  Let’s say your child takes a bath every day just about the time that daddy gets home from work.  One night, dad has to work late.  At bedtime, your child snuggles with you and asks to take a bath.  This seems odd to you, but slow iterative questions determine that he believes that if he takes a bath, daddy will come home.

So my empathic approach, as always, directs our technique to take its cue from the child.  This brings up...

5.  Dr. Wolffe’s Thinking Rule:
Concrete thinkers need concrete actions.  Magical thinkers need magical actions. 

There is no intervention for supernatural issues except for supernatural interventions.  If you wanted to help someone suffering from demonic possession, would you call a surgeon?  Of course not.  You’d look for an exorcist.  How do we accomplish this for the supernatural conflicts experienced by young children, when we might not be experts in the field—and probably can’t easily find an expert.  Think about it...who is an expert on toilet monsters or witches? Maybe we all have enough knowledge for the job we need to do.

All of us, by the way, are a soup of all kinds of thinking.  My bank just changed the way ATM deposits are done.  I asked a bank officer about this, and she helpfully showed me how to drop the deposit into the night deposit slot.  I told her I’d rather change banks—it was intolerable for me to drop an envelope of checks or cash into a blind slot without any sort of record or receipt.  It wasn’t that I didn’t trust them, it was just my need for concrete security.  (Ronald Reagan said, "Trust but verify.")  Now that the holidays are over, do you feel comfortable telling your kid all you really know about Santa Claus?  And what do you do when you are cornered by somebody at a social gathering who insists on convincing you that every English word of the Bible is the literal word of God, despite your knowledge of it being compiled by a committee in London at the turn of the 17th century?  I have met plenty of scientists who follow a religion.  Does understanding the universe convince us that there is no God or that there must be a God?  Whichever we believe, no amount of moot-court argument will change a person’s faith in their belief system.

I’m not lying when I tell preschoolers that I can see an elephant in their ears.  It makes them laugh.  Even if I say I see a dinosaur or a crocodile, they still, mostly, laugh.  They aren’t worried about it because they know, within their magical belief system, that the only elephants that could be in their ears would have to be very tiny ones and they wouldn’t hurt.  Maybe they just acknowledge the elephant I see the same way they would play along with one of their younger peers, and are being indulgent with me because I’m obviously not as mature as they are.  That, indeed, is rational insight.

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.

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.

The Human Pacifier, Part 1

When Andy was 4 months old, his parents brought him to me and asked why he wasn't sleeping through the night. It was our first visit, and they had heard of me and chosen me carefully. They had not been satisfied with their original doctor, and drove about 90 minutes to see me.

They said that he was constantly hungry, and demanded to be fed every hour through the night. Mom was anchored to the co-sleeper, which enabled her to get what little rest she could. At least with this arrangement, when the baby awoke, she could give him a quick feed without getting out of bed, and then both could get back to sleep. Dad was now sleeping in the other room, because he couldn't function at work after being awakened every hour.

Insatiable hunger can be a sign of a serious medical problem. As you can imagine, however, the desire to eat nonstop usually appears in those who look one of two ways. The obvious one is very fat, since if you're eating much more calories than you expend, your body stores it up (welcome to my world). If, on the other hand, there's some innate—presumably pathological—drive within you to eat and eat, but it's because your body isn't absorbing the nutrients it needs and therefore isn't sending your brain the signal that you're full, it's possible to be insatiably hungry and yet be starving. There are many malabsorption syndromes and diseases like this. Perhaps the most common is Cystic Fibrosis, which causes the pancreas to fail in the production of key enzymes and factors that help us absorb and digest different nutrients and fats. If you don't absorb fats, you miss out on a lot of calories. All of this is simply to say that I take seriously the observation that a child is insatiably hungry.

Note that if your child were insatiably thirsty, get your kid to a doctor right away.

But there's a reason we do growth charts. The happy baby smiling and laughing with me was at the 50^th percentile for weight, height, and head circumference. He wasn't thin or fat. He was exclusively breast fed. Though it's possible to overfeed a baby who's breastfed, it's a lot more common in bottle-fed babies whose parents, for whatever reason, use the bottle to soothe the baby. Since a baby sucks for comfort (they are often seen on ultrasound sucking on their own hands or fingers in the womb) and sucks instinctively (they will suck on a stick or anything placed in or near their mouths), these parents get the mistaken impression that if the baby is sucking on the bottle, the baby must have been hungry. Andy had not been overfed.

Though many people wait until 6 months to start solids, and I generally recommend that too, this was an exception. I thought that if we started solids right away, at 4 months, it might help. Solids of all kinds generally move through the digestive tract much slower than liquids. And much, much slower than breast milk, which is very easy for the baby to digest. My thinking was that if the solid feeding were at night, the baby might stay full a lot longer, and thus not awaken hungry so often. Great idea, I was assured by the parents, and they would try it.

It didn't work. A month later, they had driven all the way to my office for follow up. Not from the drive alone, they both looked exhausted. The baby was 5 months old and awakening every hour. He did great with the solids, still rice cereal, once a day. He continued to be at the 50^th percentile for growth. I had to take a better history.

Mom said that he nursed like a champ during the day. He spit up a little but not too much. He liked the cereal they had tried. He didn't mind being put down into the swing or the car seat, but hated being put down flat. Andy had taken to shaking his head vigorously against the crib mattress when he was put down, and now he had a little red area there that they think was caused by this.

I asked about the specifics of this 'insatiable hunger' that mother described. She said that almost like clockwork, he would wake up every hour during the night and make some noises—not crying exactly, but she said that she knew that if she didn't nurse him right then, he would escalate this into a vigorous cry and it would be much more difficult to get him back to sleep. So she now hears these little noises, and wakes herself up, picks up the baby, nurses him, and he goes right back to sleep. This process repeats every hour through the night.

Each feeding lasts, she said in response to my asking, about 1-3 minutes. She doesn't change him, because that, too, would wake him up more and make it tougher to get him back to sleep. How much, I asked her, did she think he was really getting during those feedings. “Not much,” she admitted. “I feel like a human pacifier.”

The situation in brief:

1. Baby won't sleep solid 2-6 hours at 5 months;
2. Mother not getting a sustainable amount of sleep;
3. Father sleeping in another room.

Are the following facts related:

1. The baby is insatiably hungry, but is growing normally;
2. The baby hates being horizontal, but is OK in the swing or carseat;
3. The baby shakes his head on the crib mattress;
4. The baby nurses a lot during the day.

And lastly, what exactly is my job and how do I perceive my role in this family's life? Here are some choices:

• The baby is growing and developing normally, so I can reassure the parents that they will all get through this difficult time and that they should return in 2 months for the next scheduled well-baby visit. (This, by the way, is the 'standard of care.')
• I should try to diagnose the reason for the baby's frequent awakenings, and treat this or at least help the parents understand this.
• I should avoid 'medicalizing' this normal variant of infant behavior and development. I shouldn't agree with the parents that the baby has a problem. It's their problem having difficulty living in their otherwise-normal baby's life. Why does every minor inconvenience need medical intervention? Does this require a diagnosis?
• Is the baby suffering? After all, he's my patient. If the baby—laughing and smiling with me in the office—is none the worse for wear, everything else is incidental to me as his physician.
• Do I try and fix this? In the early 19^th century, a popular medicine for babies was Godfrey's Cordial, a liquid mixture of molasses, sassafras, and opium (sometimes brandy). The good news is that it worked great. The bad news.... If I decide to try and fix this, what exactly do I fix? What's broken? What, when all is said and done, is my job?

Next post: My analysis and decision process at the end of the visit.

Repeated Lessons

A little hydrocortisone cream was all that was needed to clear up the rash caused by the calendula. The parents had noticed a little rash, and did what parents everywhere would do. They went to the ‘natural pharmacy’ and asked what would be good for a rash.

The rash caused by the calendula cream cleared up within a day or so of starting hydrocortisone. This seemed to control the baby’s mild eczema. So maybe it was natural for me to suppose that this aspect of the baby’s care was under control. when I was in the house, examining the baby on her changing table, I noticed a bottle of moisturizer next to the table. I said to the parents, “That’s for you, right?” The mother said that she used it on the baby. I asked her why she used it on the baby—she said that it made the baby’s skin soft. Was the baby’s skin soft before using the moisturizer? We had a talk about what the baby actually needed on her skin. This baby in particular, given our experience with her eczema and reaction to calendula cream, had sensitive skin at very least.

These were the parents for whom I had to spend a half hour explaining why the hydrocortisone cream wasn’t a dangerous steroid. Even as their baby cried with her rash. How long did the sales clerk have to explain the safety of calendula?

So when they called and said that they need to put their baby to sleep on her stomach, I suspected some detective work might be needed.

It seems to be true that some babies just prefer to sleep on their fronts, and not on their backs. Unfortunately for them, the epidemiology is fairly convincing. Babies placed on their tummies to sleep have about 6 times the risk of SIDS. The right thing to do would be to try and convince these parents that putting her on her back would be the safest thing for the baby.

They told me that the baby didn’t mind being on her back when she was on the changing table. Didn’t mind when on a blanket on the floor. In fact, the baby didn’t mind so much when first placed in the co-sleeper at the beginning of the night. But she would wake up with increasing frequency as the night went on, and was screaming when put down on her back in the early hours of the morning. Desperate at this point, they put her down on her tummy, and she quickly fell asleep.

Maybe it wasn’t the position that was bothering her. I asked them to describe the co-sleeper for me. I asked for and was told all the details. The padded sides were of undyed fair-trade cotton, and the frame was of sustainably-harvested wood, unpainted and unstained. The baby was placed on a very soft unbleached untreated natural Australian fleece.

I stopped them at the fleece.

Wool allergy is actually rare. Most of the people who get itchy with certain types of wool fabric are not truly allergic. They have sensitive skin and it’s irritated by the tough wool fibers. But people can be allergic to a class of natural chemicals called wool alcohols. These chemicals are a major component of lanolin. Lanolin is in a lot of the skin lotions and creams, including medicated creams, that we put on our skin. It’s the major component of creams used on breastfeeding moms.

I suggested they remove the fleece completely, and use a folded towel as padding. They weren’t happy with this plan, since the fleece was sent to them direct from a relative in Australia. I suggested they use a plastic trash bag over the fleece, then a baby blanket or two to keep the baby from getting too sweaty on the plastic. That night, the baby slept on her back.

What was happening was contact dermatitis, an itchy eczema-like rash that we get from something we come in contact with. At the beginning of the night, it wasn’t a problem. As time passed, the baby’s back got more and more irritated. When it was irritated, it became more and more sensitive. The more sensitive it got, the more irritated it became with continued contact with the fleece. By the end of the night, the baby was really uncomfortable and unhappy. When they put her down on her tummy—which was not irritated—she calmed right away and went back to sleep.

These caring parents had the best intentions for the comfort of their baby. My role was really being a seasoned detective, who might know 'usual suspects' when I meet them.

This is a baby with sensitive skin. We should learn, eventually, to be sensitive to that.