Saturday, June 26, 2010

Things That Make Parents Worry: The First Month

There are several normal things that make parents worry the first month.  Here are the typical concerns:

Stuffy Nose. Infants around a month old tend to have a congested nose.  This congestion leads to noisy breathing.  Often parents interpret this as "wheezing".  However, wheezing is actually a sound heard in the lungs and typically cannot be heard without a stethoscope.  This nasal congestion drives parents crazy, but rarely bothers the infant.  Using nasal saline drops (available at any drug store) and trying to aspirate any mucus from the nose is about all you can do for this congestion. Or you can ignore it since it is normal part of being one month old, and, remember, you do not have to fix normal.

Gas.  And you thought your newborn was gassy?  At one month old, it is surprising your baby does not float off into the sky because of excessive gas.  See fixing normal for more on gas.

Fussiness.  Babies at 1 month old are often more fussy than they were initially.  From around one to two months old many babies can be colicky.  We do not know what causes colic or how to fix it.  It too can be considered to be a normal phase of infancy.  These baby cry a lot and are hard to sooth.  They tend to be gassy and parents believe the baby's stomach hurts.  The severity of colic can be mild, very bad, or anywhere in between.  Often there is a pattern to the fussiness, with early evening being the most common time infants get fussy.  Strange things often sooth the baby, such as turning on the vacuum cleaner, turning the radio to static, or driving the infant around in a car.  The good new about colic is that nothing is wrong from a health perspective with the baby.  Colic goes away and the infant is fine.  The most important thing about colic is for parents to find a way to maintain their sanity during this tough time. 

Rash.  There are two rashes that show up at this age.  One is infant acne.  This is related to exposure to mom's hormones when the infant was inside the womb.  It presents as pimples on the infant's cheeks.  Another rash is called seborrhea or cradle cap.  It presents as dry, scaly skin on the scalp or flakiness in the eyebrows.  With seborrhea there typically is also a red, prickly rash that goes down the cheeks, around the ears and down to the upper chest.   Both of these rashes go away without treatment.  However, if seborrhea gets bad, washing the infant's scalp with Selsun Blue shampoo every other night for a few weeks can help it to resolve. 

Congratulations!  One month down and only 215 more to go until she is 18 and leaves for college.

Wednesday, June 16, 2010

Watchful Waiting: A Powerful Diagnostic Tool

Childhood is full of self-limited illnesses. Kids get sick and kids get better. The majority of childhood illnesses will get better on their own. Because of this, observation and "watchful waiting" is often the most useful diagnostic test at the pediatrician's disposal.

Parents are often confused about the need for testing. Their experiences with adult medicine is typically full of lab tests and imaging studies. Unfortunately some parents equate the quantity of testing with the quality of care. Choosing observation is often viewed as not caring or not taking the complaint seriously. So there is an intrinsic struggle between what the pediatrician feels is needed, the parent's expectations, and the risk if something is "missed." The skilled pediatrician can navigate this rocky road and have happy parents and good outcomes. This is the art of medicine.

Why not order more tests?

There are several reasons why ordering blood test or x-rays is not always the best choice. Testing often leads to false positive results, which often leads to more testing. This runs up healthcare costs and puts kids through unnecessary procedures. Test results often do not change the management of the child's illness. If the same course of action is going to be recommended whether a test is positive or negative, the test has no value to the child's management. Finally, testing can have negative side-effects. A needle brings on anxiety in children and it hurts. X-rays and CT scans expose children to radiation.

It is estimated that 1 child out of every 1000 to 5000 children receiving a head CT scan will die from cancer attributable to the radiation from that scan. This cancer would likely show up decades later, but the process was started with that radiation exposure. Pediatricians see children who fall and hit their head or who complain of headaches almost daily, giving ample opportunity for ordering CT scans and possibly causing a cancer later in life. Even the most anxious parent would likely accept watchful waiting given these numbers.

Is there a time when testing should be done?

Absolutely! Technology has given medicine the power to diagnose, treat, and cure illness, and there is a time when it should be utilized. If a toddler is in a car wreck, hitting his head and losing consciousness, and now he is vomiting excessively, he absolutely should receive a CT scan of his head. Cancer risk be damned. Physicians are taught to balance the risk of doing something versus observation, and sometimes the scales lean dramatically in one direction or the other.

Trust and communication.

Trust is a crucial part of this equation. The parents need to trust the doctor's skill and the doctor needs to trust the parent's capacity to observe and detect signs of a worsening condition. The doctor must be able to communicate warning signs and parents need to feel free to contact the physician with questions or concerns.

With modern medicine there has been great leaps in technology that have enabled us to do things once unimaginable, yet watchful waiting remains the most powerful diagnostic instrument that the pediatrician has in his or her bag.

Saturday, June 12, 2010

Fixing Normal

Imagine taking your car to the mechanic and asking him to fix the light in the glove compartment. You explain that every time you open the glove compartment the light turns on and then when you close the glove compartment the light turns off. Something is wrong and it needs to be fixed. The mechanic patiently explains that the glove compartment light is not broken. It is operating normally. But you remain skeptical. Maybe you go to another mechanic to get a second opinion. Maybe you search the internet and find a remedy recommended by a lady named Cheryl in Idaho.

Such is the life of a pediatrician. We are constantly being asked to fix normal, and if we can't (or discourage trying) parents often look for answers themselves. A common example is infant gas. I am convinced that being gassy is a normal part of being an infant. Why else would I have 5 parents a day ask me why their infant is so gassy? I typically explain that gassiness is normal and that, if I had an answer for gas, I would have retired long ago. Yet, many parents are convinced that something is wrong and it needs to be fixed. They buy gas drops. They buy boutique formulas "for gassy infants." They buy special bottles and nipples. They try herbal remedies. They watch YouTube videos on massage techniques for infant gas:

There is a whole industry designed to fix the normal gassiness of infants, a whole industry designed to placate parent's anxiety. Anxious parents love it, because they are doing something to make their infant "better" from a perceived problem. The placebo effect courses through the parent's veins. In the above video, who is benefitting from the massage? The parent is probably benefitting more than the infant. Sure the infant enjoys the stimulation and interaction, but is the parent truly fixing something?

In the example of infant gas, parents are most likely doing no harm, but there are examples where parents are so convinced they have to fix something that is normal, that they put the infant at risk.

Understand what is normal. Accept it. Embrace it. Laugh at it. But you don't have to fix it.

Thursday, June 10, 2010

Things That Make Parents Worry: Week 1

There are several things that parents will notice the first week of life. Most of these concerns are related to physical appearance. Fortunately, these are all normal and anxiety is not warranted.
  • Flea-bite Rash. Infants will often have a rash that looks like several flea bites at various places on the body. This is called Erythema Toxicum. The name sounds awful, but the rash is of no significance. It goes away in a few weeks
  • Breast Buds. Because infants have been exposed to mom's hormones for 9 months, their breast tissue may be enlarged. This will feel like a knot under the nipples. Yes, boys can develop this too. The breast buds usually shrink away by 1-2 months old.
  • Vaginal Discharge or Bleeding. Little girls, once again because of maternal hormones, will often have a clear to white colored vaginal discharge for several weeks. They can even have some vaginal bleeding, like a women's period, during the first week or two of life.
  • Bowed Legs. Legs and feet will often look odd shortly after birth. Because of the infant's position within the uterus, the lower extremities can be bowed and the feet can often assume an unnatural position. This tends to go away as the infant grows.
  • Cone Head. Babies will often have molding of their skull from the birth process. The infants skull was designed to contort in order to fit through the birth canal, and it will often retain an unusual shape for the first week or two of life. Likewise, a vacuum extraction will almost always lead to impressive swelling and sometimes bruising of the head.
  • Purple Hands and Feet. Babies have poor circulation to their extremities. This leads to acrocyanosis, purple or blue hands and feet. This is not a sign of trouble breathing or trouble with the heart.
  • Dry Skin. Babies will shed layers of skin shortly after birth. This is related to living in water for 9 months. This will resolve in a few weeks and generally does not require any lotions or creams. Sometimes the skin can actually crack and bleed a little, especially around the ankles. In this case, you can put some Vaseline petroleum jelly on the area twice a day.
Your baby certainly does look odd, but fortunately she is normal!

Saturday, June 5, 2010

Anxiety That Works: Breast Feeding 101

Some parents are not interested in breast feeding, and that is fine. Many, however, want to but "can't." This is for them.

There are many reasons why a mother may be unsuccessful at breast feeding. I want to discuss the most common ones. First, it is important to understand that formula is an invention of the 20th century. Before this breast milk was essential for survival. No other species uses infant formula. So, believe it or not, women were designed to be able to breast feed. Without this capacity the human race would have ended long ago. So why are so many well intentioned women unsuccessful?

The most common reason that I see is improper expectations. No one told the mom how hard breastfeeding is. The first week of breastfeeding is hell. Expect that and you will be ready to go. It gets much easier, but during the first week, you will have major doubts about how well you are doing, your nipples will be sore, your baby will not be satisfied, and dads will be stressed as well.

There is a natural cycle that takes place. The baby is hungry and cries. The mother reads this as a sign of hunger and puts the baby to the breast. Not much milk is produced, so the baby is not satisfied. The unsatisfied baby either remains on the nipple or falls asleep for a short period and then wants to eat again. Mom puts baby on the breast again. In order for the mother to start producing milk she must receive this sucking, and a hungry baby is going to want to suck more than a full baby. This sucking causes mom to produce a hormone, called oxytocin, which is responsible for making milk. So, yes, you are "starving" your baby, but that is what nature intended. A hungry baby yields more sucking and more sucking produces more milk. A mom who is concerned that she is not giving her baby enough nutrition is going to be inclined to keep putting the baby on the breast, which leads to more sucking. You see how that works? Nature is pretty smart.

Problems arise when that anxiety hits, and, instead of putting the infant on the breast, many families jump to formula. The baby is satisfied and everyone is happy, but breastfeeding is essentially over. It is important to embrace the anxiety (this is one of the very few times I will suggest this) of breastfeeding. This is what nature intended. Anxiety is part of the cycle.

Giving formula in addition to breastfeeding almost never leads to long term breastfeeding. The infant gets full and mom therefore misses out on important sucking. When well intentioned families are already doing "both" during the first week of life, the chance of long term breastfeeding drops dramatically.

Likewise, the long term success for mothers who are trying to pump and then bottle feed the breast milk is pretty poor. Moms often resort to this because they are anxious that the baby is not getting enough milk. Pumping allows them to see how much the baby is taking. This may help the family's anxiety level, but it typically does not lead to long term breast feeding.

Tips for success:

  1. Relax! Trust the system that nature has designed. Understand that your anxiety and frustration is a crucial component to the system. Your baby being unsatisfied is also part of the system.
  2. Be a breastfeeding gladiator. The first week is a battle. Let nothing get in your way from being successful. Sleep, pain, and anxiety are for the weak, not the breastfeeding gladiator. Understanding the challenges that lie ahead is half the battle. Prepare yourself mentally!
  3. When in doubt, put the baby on the breast. The more sucking you get, the sooner and more milk you will produce. If the baby is on the breast for 24 hours straight, that is great! You may not like it, but you have just dramatically increased you chance of successful breast feeding.
  4. Fight through the soreness. There is no way around this, your nipples will get sore. Sometimes they will crack and bleed. Continue putting the baby on the breast. The soreness will improve.
  5. Ask for a Lactation Consult prior to leaving the hospital. Most hospitals will have a Lactation Consultant on staff to help breastfeeding mothers. If one is not available have a nurse watch how the baby latches on and feeds. They can be very helpful. (However, there are nurses that will see the breastfeeding frustration and recommend that you give the baby a bottle. Politely refuse, she does not know the harm she is doing.)
  6. Trust the baby's weight. This will show how well you are doing. All babies lose weight in the first 3-4 days of life, but they should be getting back to their birth weight around 7-10 days old. Ask you doctor to recheck the infant's weight if you are concerned about how you are doing.
  7. Let your pediatrician tell you when things are not going well. As I mentioned, you are going to be convinced that the breastfeeding is not working. Ignore that voice in your head, listen to an outside source that knows the process. There may be times that supplementing or pumping is recommended, but parents, who are overwhelmed with breastfeeding anxiety, are often not good at making that decision.

Finally, around day 3-5 of life, moms will start producing milk. This is typically an overwhelming sensation. When a mom says that her milk "might" be in, she is not yet producing milk. If the answer is, "oh, yeah," then her milk is in. Once a mom has made it to this point, the chance of long term breastfeeding is excellent.