A Baby with Diarrhea

 
The mother that called me wasn't in a panic, and that's usually reassuring to me. She told me that her 3-month-old baby had diarrhea for 3 days. At that age, with nursing well-established and generally consistent growth, they can usually weather a brief illness without too much difficulty.  But I asked the usual questions. He didn't have fever or a rash. He didn't seem to be in pain, he wasn't unusually irritable. In fact, he was nursing as usual, seemed happy and playful as usual, and was having a lot of wet diapers, as usual. But he was having diarrhea in small amounts a dozen or more times a day.  It started 3 days ago, and nobody else in the family was sick. Did they change what he was getting? I wondered if they had started to introduce a baby formula to which he was having some sort of reaction.

"No formula," his mother said. "Except...," she paused here with a giggle. “Well,” she said, “we were in McDonald's and the baby was hungry and he kept looking at us and seemed to be grabbing at our food.  So we took a little piece of cheeseburger, kind of mashed it up, and fed it to him.  He really liked it!  We were careful not to give him a lot though.  Everybody knows that kids shouldn’t eat too much fast food.”  The diarrhea started the following day.


“Oh,” I said.  “Uh…did you give him anything at home?”  I had a feeling about what to expect.


“Well, he liked the cheeseburger so much that we wanted to see what else he’d like.  We were having spaghetti, so we gave him some of that.”


“Sauce of some sort with that?”


“Of course.  Who eats spaghetti plain?”  Not 3-month-old babies at their house, for one.  Within the last 3 or 4 days, the baby, who had never had solids before, had at least a little bit of cheeseburger, pasta, marinara sauce with meat, mushrooms, at least 2 different kinds of sausage, several breads with and without butter, and just about everything else the parents ate.  And, the mother pointed out, “He really liked the ice cream.”

Usually, the first solid food we introduce to babies is rice cereal. Sometimes it's as early as 4 months, sometimes as late as 6 months. Much later than that is still compatible with life, of course, but the nutrition seems to be less complete, the child doesn't learn the skill of eating, and the maturation of the digestive system is delayed. Aside from This Island Berkeley, perhaps, places where nursing is the exclusive source of child nutrition extending well beyond a year are usually places of great deprivation.

The recommendation of starting with rice cereal has some sense behind it. You may know people who have reactions to wheat or just trouble digesting it. But though possible, this is much less likely with rice. It's reasonably inexpensive, and readily available in the supermarket, fortified with iron. It can be mixed with breast milk, formula or water. It cam be put into a bottle or made thick enough to stand on a spoon.
The iron is important. Formula in this country is fortified with iron. Breast milk has little iron, but what it has is especially absorbable to the baby. Even in Red States, babies don't generally get a lot of beef or related high-iron foods until they are walking. As the first year goes by, the store of iron-rich red blood cells inherited from the baby's mother are gradually used up.  By 9 months or so, these are all gone, and babies whose diets are low on foie gras don't have a lot of concentrated dietary sources. That's why we test every 9-month-old for iron (hemoglobin level, actually) at their well-child visit.


Here's what happens, as every parent knows. The first time a spoon of cereal goes in their mouths, babies scrunch up their faces and scrape the stuff off their tongue and out of their mouths. Never having had anything like this before, they wonder why you are putting a spoonful of what could be sand in their mouth.   It had never occurred to them that food could come in some form other than liquid.  They get the idea eventually, of course.  This process, often requiring patience and persistence, is important. It's not the nutritional value of the cereal that's so essential. It's the learned skill of manipulating solid food in your mouth to get it to go down the right way without choking. We've all had that horrible sensation, and we've had a lot of practice. For a baby, this is a skill for life. Still, rice cereal is bland and not every baby likes it. 


This is a good spot to tell an absolutely true story, which I freely share with many first-time parents who struggle with teaching a baby to eat.  In my graduating class at medical school, there were about 100 graduates.  Every one of them—with no exceptions—was on solid food.   At this point, most of these exhausted and frustrated parents look at me and wonder if they picked the right doctor.  Every one of my medical school classmates, I assure them, learned to eat solids at some point between being 4 months old and medical school.  Though I couldn’t say exactly when.


I’m happy to report that the baby with diarrhea didn’t have a dreaded infectious gastroenteritis.  Or if he did, it just happened to resolve at the same time he stopped getting his meals at a drive-though window.  Do you want fries with that?






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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.