This post is about my anger.

Why aren’t supplement ingredients on the label of the product?

How come most prescription products come with a sheet of paper the size of a tablecloth, folded 1024 times so it ends up the size of a stamp, completely covered with tiny print that is required bylaw to mention every rare adverse event that happened to subjects during a clinical trial?  Because it’s required.

If the product is effective as a drug, and is used as a drug, why aren’t there clinical trials? 

Why do I need to spend 2 hours looking this stuff up?

Why didn’t the other guy review with the patient all the potential side effects, the risks of interactions, the risks of hypotension and collapse, of bleeding spontaneously, of increased menstrual cramps, flushing, lactating, breast pain, odd body odor, stomach pain, gas pain, diarrhea, allergic reactions, rashes, itches?

Why is it that I have to reassure myself that the undocumented sourcing of slaughterhouse discards of adrenal and thymus glands and testicles from many animals of several species won’t require disclosure of the risk of Bovine Spongiform Encephalopathy—Mad Cow Disease?

Why should I have to worry about the products claiming to be better and natural sources of vitamins because they are derived from algae?  The fact that algae are being proposed to de-contaminate toxic heavy-metal superfund sites, because they so selectively accumulate this kind of poison, shouldn’t be a problem for people taking algae every day, right? 

If I prescribe a medication, and there’s a problem interaction with one of the supplements, who will rush to help the patient?  Who will answer the phone on the weekend, or at night?  Who will spend the time to figure it out?  Who will be blamed?

And it did, indeed, occur to me after hours of research into these products and their ingredients, that I looked up what was on the label.  There is no regulation requiring that what is on the label is exactly what is in the pill, or if it’s fresh, or if it’s not contaminated, infected, or accurate. 

Are you really, really sure you want your kids taking this stuff?  Is it really better than whatever you consider a drug?  Did the person at the health food store tell you about all the side effects and interactions?  Did that nice woman in your mom’s group?

I noticed that my patient had some nasal allergies.  I didn’t make anything of it—I have some of these too.  But I spent a couple of hours making sure that the medication I was prescribing didn’t have some kind of interaction with the 8 nutritional supplements recommended by her chiropractor.  I wasn’t too concerned about the vitamins, whether they came from algae or a Swiss pharmaceutical company.  Deep down on the list of one of the products—mostly vitamins and minerals in this one—was a quick mention in the ‘other ingredients’ section:  barley grass.  I wondered if it could be triggering her grass allergies in the middle of winter.

And there was another product with Globe Artichoke as an ingredient.  It’s in the same flower family as marigolds and ragweed.

Yet another product contained Milk Thistle.  It’s in the same plant family as, sure enough, marigolds and ragweed and artichoke.

But it probably didn’t help that buried in the long list of ingredients in another product was dandelion. Lots of people are allergic to that, too. She wasn’t taking antibiotics, so I wasn’t worried about the dandelion lowering the levels of antibiotics in her blood.

She was taking a product I often recommend:  Fenugreek.  It’s a common spice in Indian recipes, but that’s not the way I prescribe it.  I use it with new mothers struggling to develop their milk supply.  Not with all, and not with whatever dose they want.  I write down for them exactly how many milligrams, how many times a day, what they should expect, and what side effects they should look out for.  Just like any medication I prescribe. 

Because I was very experienced with the use and dosage of this product, I don’t expect—though that doesn’t mean it’s not possible—that this teenage girl will start leaking in an embarrassing way during 2nd-period geometry.  Should I warn her that it can increase uterine cramping? 

I found out that many of the product ingredients interfere with blood clotting.  Some have effects on blood pressure.

I’m happy to admit that somebody with high blood pressure might do quite well on Reishi Mushroom.  Maybe better than on conventional drugs.  But it’s still a drug.  Some studies show that it decreases platelet activity.  That’s generally a good thing in heart-disease patients.  And anything that lowers your blood pressure increases the risk of fainting, sometimes not at the most convenient moment. 

What is so annoying is the obvious elephant in this room.  It’s a supplement when I try to supplement my diet with some extra fruit and vegetables.  But these are drugs.

The natural medicine folks want to have it both ways.  If the plant products actually work medically, they are better because they work ‘naturally.’  But if they work medically, and do all the things claimed—like serious changes to bleeding, blood pressure, or the immune system—why aren’t they drugs?  If they don’t work medically, why are they recommended? 

I asked some typical new-prescription questions.  Was she taking any medications?  Did she have any allergies?  No, and no.

It was the first time I met her, so I asked about her stuffy nose that she kept rubbing.  Well, she did have those kind of allergies.  As we went through some of her medical issues, she revealed some typical teenage-girl symptoms.  I asked if she has tried to do anything about these, does she take ibuprofen, and so on.  She said that her mom took her to the chiropractor, and she takes some supplements that were recommended.

Which supplement?  She didn’t know.  She said it was 8. 

“Eight ingredients?” I asked.

“No,” she said.  “Eight separate bottles.”

“What do they do?”

“I don’t know,” she said, earnestly.  At my request, a parent emailed me the list.

Don’t expect a complete horror story—this isn’t one.  Most of the products were basically vitamins.  Calcium from seashells, and B-vitamins from Blue-green algae.  There were a couple of surprises, and some insight from my research.

Funny thing about algae:  it concentrates what is in the water it lives in.  So it is a concentrated form of protein and vitamins.  But it is often found with high levels of heavy metals.  And sometimes it gets contaminated with microorganisms you probably don’t want.

There were a number of products with names that didn’t give a clue about what they were for.  So I looked up the manufacturers, got their list of products, then found the ingredients. 

As an aside, I have to imagine that the target market for many of these products has its bulls-eye right here in Berkeley, where the vegans look upon the vegetarians as insincere poseurs, ersatz Dr. Strangelove apologists for global thermonuclear annihilation.

So imagine my amusement and the gleeful profundity of my schadenfreude when I found that the product called Okra Pepsin (sounds vegetable-y, right?) contains what the manufacturer claims to be a ‘proprietary blend’ (they don’t need to worry about me stealing the secret formula) containing bovine orchic extract.  Perhaps they use an extract of orchids that look like cows.

Not exactly.  They go to slaughterhouses, ask if there are some testicles lying around, and then, you know, extract.

Why did this teenage girl need this?  I couldn’t guess.  She was also taking products using ground thymus glans from slaughtered animals including cows and sheep and maybe other species.  And another product with adrenal glands.

Hey, in some places they consider organ meats a delicacy.

But that's not the topic of this post. Embedded in the study publication was this item, which received no other discussion by the authors:

"Of all content types included in the survey, only 1 was not rated as extremely important or very important by the majority of parents: materialism or things that promote materialistic attitudes."

I report this from Berkeley California. In Berkeley, a nuclear-free zone, the sprawling Whole Foods market across from my office is filled with shoppers loading their fair-trade renewable-resource unbleached hemp-fiber shopping bags, filled with out-of-season organic produce flown in from New Zealand, into the back of the Range Rovers required to ensure the safety of their unvaccinated kids when driven by the au pair every morning a few hundred yards to the private Waldorf preschool.

I'm not in favor of unfiltered access by children to everything an adult or even teenage mind can imagine or put on the internet, in a game, or available some other way.

But materialism gets a free pass? Nearly all media produced with a child audience in mind is marketing. It is hard to find content, even content I love, without this. I think Monsters Inc. is one of the best movies ever made. But Pixar (and Pixar/Disney) has clearly taken a lesson from George Lucas, and licensed their trademarked characters widely. If I could afford them, I would have Monsters Inc Band-Aids in the office. It isn't unusual for your kids to see products in the store or owned by their friends and beg for them or ask to see the movie or TV show.

What about the materialism, not considered a problem by most parents, apparently, of so many of the television shows available on networks watched by preteens? Not limited to product placement, this materialism equates success with wealth, big houses, fancy cars, and so on.

I'm not a monk. I like nice things, fancy restaurants, and so on. I sometimes make purchasing decisions that in retrospect seem impulsive. But at this point in my life, I no longer believe these things constitute success.

I’m appalled that the parents surveyed identified depictions of materialism as unworthy of rating. They want to know if their kids will hear the word 'butthead,' but don't care that nearly all of the live action shows on Nickelodeon have characters whose goal is to achieve something financial or monetarily valuable, and they get general peer approval for it. For me, I would like to know if my kids are spending their screen time, no matter how strictly limited, watching infomercials for getting rich in the 'cash flow business.'

For what I suppose is the same reason parents don't focus on the aspect of media content, however, there is very little actual research done on this issue. So we don't really know how powerful this message is. But if it's like so many other subtle media messages, it gets a direct pipeline into the kid's brain.

Still, just like those other media messages, the real way to combat unwanted influences has been repeatedly shown to be modeling at home and not by media ratings. If the parents aren't confirming these media messages, they generally won't stick. So it's great to tell your kids they aren't allowed to eat snack food, but they see you on the sofa with a big bag of potato chips, you will need to do a better sales job. I guess I don't have to mention that all the lectures you received as a child (think back now) about the way you were supposed to act, the things you were required to do or forbidden from doing, just didn't take when you had the freedom to ignore these rules. While it's normal to push the envelope at certain developmental stages, we are most strongly influenced by what we witness our parents doing with our own eyes.

If you don't want your kids to use bad language, don't use it. For everything else, ask yourself 'What would I want my child to do?'

The latest fad among professional educators is 'zero tolerance.' 

A patient of mine with a chronic pain condition was found in school to be taking Tylenol.  She was suspended.  I wrote a letter to the principal and superintendent of the district, hinting that they were potentially liable for interfering with her required medical treatment. 

I have just written a letter to a high school math teacher.  I told him that upon my orders, one of his students is drinking a lot of water.  I didn't tell him, because if was none of his business, that I instructed the kid to do that because he kept fainting during exercise.  Because of my instructions, and the cooperative patient who followed them, bathroom breaks were an unavoidable consequence.  The math teacher didn't buy this when the student explained it, and had decided that he would not allow any student to get up during class to use the toilet.  I understood the potential issue, but maybe the solution to the teacher's concern, however delusional or real it might be, is to make the class more fun and interesting.  Even so, my patient was an excellent student and simply had to pee a lot.  In these kind of examples, zero tolerance is silly. 

I have written a lot of letters to schools lately.  For all the kids who got in trouble by bringing to school hardcore drugs like Midol or asthma medicine or allergy pills, how many get caught with ecstasy?  I wonder if zero tolerance policies for 'drugs' really makes marijuana less available to a high-school student who wants to get some.

Since many studies have established that children who are bullied can have lifelong scars, and are unhappy and less healthy and have a higher rate of all sorts of bad things, schools have decided that they needed to do something about the problem. The things they had been doing for the previous, oh, centuries just haven't been working. Since they had no idea actually how to stop bullying, they have decided to apply a zero tolerance policy. They would not tolerate bullying, not even a little bit.
Unless they actually see some, that is.

A kind and sensitive 7-year-old patient of mine was brought in by his mother.  She said that he’s been having a lot of stomach aches.  She hadn’t noticed any pattern, but with my questioning, it became clear that they were mostly in the mornings on school days.  I examined him, and asked his mom if I could speak to him privately.  As soon as the door closed behind her, he started to cry.  I found out the names of the 5th-grade boys that had been bullying him.  I asked him if it was OK for me to tell his mom.  He nodded.

I asked her to return and told her the names of the boys, and the nature of his illness.

She told me that she hadn’t known the names, but she had found out about the bullying a month ago.  She talked to the teacher, who said these children weren’t in her class, so she couldn’t do anything about it.  The mother talked to the principal.  The principal said that they have a zero tolerance policy for bullying, so it just doesn’t happen in that school.  Perhaps, she suggested, this was just a typical schoolyard conflict typical of, you know, boys.

The tiny kernel of truth in this shocking, offensive, ignorant bias is that this is nothing new.  There have always been bullies and there always will be.  It’s human nature.  There are at least as many girl bullies and victims as boys.  They might not threaten physical violence as often, but what mean girls do to other girls is often sadistic and awful.

He was being bullied mercilessly at school by some boys in an older grade. They threated to hurt him.  They would hurt him if he told anybody.  They made fun of him and laughed when they made him cry.

After our visit, the mother told the principal the names of these boys.  It should go without saying that the principal knew who these boys were immediately.  This child wasn’t their first victim.  The principal said she’d take care of it.  A week later, the mother was called to pick him up from school.  He was sitting in the office complaining of a stomach ache.

The mother asked the teacher what she had done about these bullies.  She said that she had ‘talked to the boys.’  He refused to go to school for several days.  The mother was missing work.  the principal suggested that maybe the problem would be solved if the child simply stayed home.  The mother suggested that maybe it would be more consistent with the zero tolerance policy for the bullies to be kept at home. Ultimately, the principal said she would again 'talk to the boys.' What would she say? That if they do it again she will consider applying a tolerance policy less than the 100% tolerance the school is now using?

The child starting having anxiety attacks, depression, stomach aches, headaches.   After a couple of months of inaction by the school to protect this child, I wrote a letter that simply alerted the principal to several facts.

1. I knew about this.
2. I was keeping a written and official record of it in his medical chart.
3. The inaction by the school was having severe medical effects on the child.
4. These have a great deal of potential to get worse.
5. Medical care is very expensive.
6. Preventable medical problems that were not prevented can unfortunately often result in expensive litigation with terrible surrounding publicity.
7. I am sending a copy of this letter to the head of the school board.
8. I am sending a copy to the District Superintendent
9. I am sending a copy to the State of California Board of Education President

I don’t know the ultimate outcome yet.  But this is part of my job.

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.

Racial differences in response to cardiovascular medication.  [It’s pretty readable for non-doctors.]

It has been found, generally speaking and for example, that there’s a difference in response to a common blood anti-clotting medicine in Black, White, Hispanic, Asian people.  This could be really important to know.  Though not a cardiologist, I have the impression that treatment guidelines have incorporated some of these findings, and you might get a different dose or medication depending on your ethnicity.

Have I sold you on this? 

We have always known that different people respond differently to a given medication or dose.  Sometimes doctors have to try different formulations or doses to get the therapeutic response that will help the patient.  Clearly, there’s something about the way that patient is metabolizing the therapy that is special.  Presumably, it’s genetic.  Note—it might not be.  Grapefruit and grapefruit juice, for example, is a very potent inhibitor of (and this is common knowledge) the CYP3A4 form of the P450 enzyme.  A lot of drugs get digested by this enzyme.  Blood pressure drugs, heart rhythm drugs, cholesterol drugs, sleeping pills, anxiety drugs, antidepressants, antihistamines, some birth-control pills, some immune-suppressant drugs and some anti-HIV drugs.  Chances are really good that you or someone you love is taking a medication affected by grapefruit, especially by grapefruit juice.  Organic or not.  Did the people studying these drug-responses ask their subjects about grapefruit juice intake?  I don’t know. 

I’m bothered by the idea of having an ‘Ethnicity’ in your child’s medical chart.

So far, a lot of the research in this emerging field of Pharmacogenetics (sometimes called Pharmacogenomics) isn’t.  It’s really PharmacoRacialist research.  There’s painfully little genetics and lots of studies of ‘racial groups.’ 

I’m not trying to be politically correct here.  I wouldn’t doubt that epidemiologic research done in a remote Chinese village is probably representative of a relatively limited genetic pool.  True genetic research in the U.S. has depended for decades on relatively closed and technically inbred communities among the Amish.  One of the reasons behind the excellent and expert genetics professionals in Utah is precisely the multigenerational stability and consanguineous inbreeding available for research.  Genetics research looks for a link between subjects.  A lot of this current research has only an ‘ethnic’ label as the common link.

Partly, it’s the government’s fault.  Seriously.  The Census is probably the most important way our tax dollars get divided.  And, perhaps with good intentions, the government wants to know about the ‘racial’ makeup of this country. 

As far as I can tell, this is the latest official information from the Office of Management and Budget, which manages the Census.  

US Census Directive 15

Everything is based on the census, and the racial distinctions are sociopolitical, no longer genetic or medically-based in any way.  If you think certain groups need to be kept track of, write your congressperson. 

From a medical ethics point of view, there is clearly emerging data suggesting that different treatments or approaches might be optimal for those with different genetic ancestries.  These distinctions are unlikely to overlap much with meaningless Census distinctions, such as 'Hispanic' (which, after years of debate, has apparently been changed to “Hispanic or Latino.”  The 'Asian or Pacific Islander' category will be separated into two categories -- "Asian" and "Native Hawaiian or Other Pacific Islander."  Hey, at least the islanders live on islands for pete's sake, at one point in the 19th-century genetically isolated in the Darwin-in-the-Galapagos sense.  My Korean and Chinese families don't think they are Japanese.  What about Filipinos or Indonesians where different islands can mean different origins.

I have a family with 2 Chinese grandparents on one side and 2 grandparents from Portugal on the other.  They recently immigrated here from Brazil--what are they?  What are their 2 adorable kids?Are they Latino because Portuguese is a Romance Language?  Hispanic because they are from South America?  Asian because the kids have those sort-of-Asian eyes?  What if a grandparent had fooled around with one of those tribespeople featured in National Geographic, with red face paint and arrows dipped in the skin secretions of extremely colorful tiny frogs?  Does Native South American count as 'Native American' here in the U.S.?  Is ethnicity defined by speaking a foreign language?  It is, according to our government, if the language is Spanish.

There’s an easy reality check.  Ask the Spanish-speaking people you know.  Believe me (and the US Census), they are all around you.  When I lived in Utah, which I considered to be the least ethnically-diverse place I had ever lived, we had a medical clinic that was pretty much 90% Spanish-speaking.  These families lived right there among, well, you know who, in Salt Lake City.  Here’s what I have noticed.  Ecuadorians hang out, mostly, with their fellow Ecuadorians.  They may have travelled through Mexico to get here, and they speak the same language (to me).  When a friend from Venezuela went out with me in Boston many years ago, he could tell immediately that people we met were speaking with accents from Peru or Guatemala or Cuba.  I’ll say he could tell if people came from Puerto Rico, but he said that he couldn’t understand much since they spoke so fast and dropped so many syllables.  He sometimes complained that he was too impatient to wait for a Colombian to finish the sentence.   He could tell when they started speaking—but not by how they looked. 

It was a revelation to me when I attended the wedding of a distant relative in Paris.  Also there were relatives from Nice (on the Mediterranean coast of France).  My relatives said it was impossible to talk to them because “…they speak with such a heavy Southern accent.”  It took me a while to figure this out.  It was hard for me to reconcile Hercule Poirot and The Dukes of Hazzard.

 [Tasteful?  Professional?  Oh come on, what did you really expect?]

What about babies?  Is their ethnicity unclear until they are old enough to refuse to eat vegetables?  Are they Latino because their parents speak Spanish?  What if their Spanish-speaking parents are descended from Caribbean slaves, and are dark-skinned, but have moved here?

I think this is an ethics discussion because even with demonstrable medical distinctions, how does the working doctor categorize the folks sitting in the exam room, and their variegated offspring?  Do we categorize patients by our personal visual assessment of their skin pigment (I treat all shades of dark kids and light kids from curiously mixed parents). 

My personal opinion is that the idea of race is a sad vestigial construct without helpful meaning.  Here's what I might genuinely need to know:  have any of the child's relatives had sickle-cell disease?  Cystic Fibrosis? Hemophilia?  It wouldn't help me to have a place on the chart for 'ethnicity.'  But in the Social History section of my computerized charting program, I will note if a child is adopted and from where.  I will note there if there are medically-relevant familial risk factors. 

And what about those medical distinctions I noted above that ‘everyone has known for years?’  Even if this were true for one very long historical era, until World Wars and intercontinental migration, it isn’t true here in California.  When I first moved here from Utah in 1999, I made a comment to one of the hematologists at the local children’s hospital about not seeing much sickle-cell disease in Utah.  She said she had a clinic full of white kids with sickle-cell, and I felt as ignorant as I was.  Here in California, every baby is screened for sickle-cell at birth (since 1990).  

Everyone has known, since 1885, at least, that Mongolian Spots (benign bruise-like markings often appearing on the lower back of babies) were much more common in Asian children.  This was first noted, as a fact, by Dr. Erwin Bälz [I couldn’t make this stuff up!], the German-trained personal physician to the Meiji Emperor.  It was only around 100 years later that these were found to be correlated with skin pigment—the more pigment you had, the greater the chances of a mongolian spot.  But they are harder to spot in babies with very dark skin.  So they were noticed more in babies of Asian descent who had more pigment that Laplanders but less than equatorial Africans.  Ira Gershwin said it best:  It ain’t necessarily so.

It turns out that the whole ‘ethnic’ idea is largely confounded by genetics.  It’s certainly true that my ancestry is tough to follow prior to immigration from southern Russia.  Nobody kept track of peasants and who they mated with.  Still, history is filled with tales of great kings who have kids with serving wenches.  And from there, it’s all down hill straight to me.  Maybe it was one of Catherine the Great's illegitimate offspring, who had a servant who mingled with regular folks that resulted in one of my great-great grandparents.  Mathematically speaking, all it would take is one productive dalliance.  You're not left out of this statistical fog if you consider yourself Native American or African American, for example.  Chances are good that sometime in the past, an ancestor of yours picked up--how should I put it--some genetic material from an ethnic outsider.  Which leads to this:  I’m descended from Charlemagne.  Yes, that Charlemagne.  Perhaps less likely an ancestor for you if your family recently came from Africa or Asia.  Your folks came from Africa in the 19th-century?  We can both attend the Charlemagne family reunion.  Just arrived?  Maybe not Charlemagne, but definitely Nerertiti.  Just like me.  Read this article from The Atlantic Magazine.  It will likely affect your view on race forever.  You can’t judge a book by its cover.

Because I don't think racial labels are generally helpful, I also believe that they are a potential problem. I wouldn't want my calling a patient 'white' when they are 1/16 Native American to interfere with their self-description. This may have legal implications, perhaps for Federal contracts or programs. Will it help them or hurt one of my patients in gaining a scholarship to define their race in a certain way, especially if whatever institution looks to their physician or medical record for verification? If I don’t think I, a fairly observant physician, can tell what race you are by looking at you, I certainly don’t have confidence that—even with training—college students working for the summer can categorize your ethnogenetic heritage when they come to your door to help with the census and try to give you a careful look in the hallway outside your apartment door by the dangling blinking buzzing insufficient fluorescent light that you’ve been bugging the cheapskate landlord to fix for months.  

I'm so grateful that you have found this blog interesting. It isn't meant to give medical advice of any kind, ever.

In this true story, I was seeing the baby every few days at first, but as the inadequate weight gain continued, I was seeing the baby every single day. I was worried about the baby! It's normal for babies to lose weight for the first few days. But they should start gaining weight within about a week or so. Babies who are born bigger tend to lose more weight at first, so it might take them a little longer to regain their birth weight.

Pediatricians often use, as a rule of thumb for this initial weight loss, about 10% as a guide. If a term baby of average weight, say 7 1/2 pounds (about 3400g), loses anything less than 10%, we usually don't worry too much about it. For this average baby, that would be about 12 ounces (about 340g).

We also have a rough guide for weight gain. On average, once newborns start gaining weight, we expect them to gain about 1 ounce a day (~30g). This slows down, of course, as the months go by.

Let's do the math. If our 7 1/2 pound baby lost 10% of her weight by the time she was 5 days old, she would weigh 6 pounds, 12 ounces. She lost 12 ounces. It would be reasonable to guess that it might take 12 days (at a rate of weight-gain of 1 ounce a day) for her to regain that weight. But she only started gaining weight on her 6th day, so she'd be back to her birth weight around day 18. That's about 2 1/2 weeks old. I'm usually pretty satisfied with anything in the 2-3 week range.

Let's do it again for a bigger baby, say 9 pounds (~4100g). Weight loss of 10% would bring the baby down to about 8 pounds 1.5 ounces. If this baby gained an ounce a day, the baby wouldn't be back to its birth weight until closer to 3 weeks of age.

Babies who are born smaller, lighter, or prematurely don't have so much extra, and the 10% rule-of-thumb really doesn't apply. Remember that the baby is not just getting food but also fluid in each feeding. If there's a delay getting breast milk or formula, that's always going to be concerning.

The blog post you commented on was an example of how I manage this as a physician, in the unusual practice I have created. If a baby who wasn't gaining weight was brought to urgent care or to a doctor for the first time, it would be understandable if that doctor, alarmed by the poor weight gain, felt compelled to get some tests to make sure the baby wasn't sick in some way. It would also be reasonable to discourage breastfeeding, at least for the moment, and encourage formula use. Maybe the baby would be admitted to the hospital for intravenous fluids. None of these interventions would be wrong or bad care.

I wanted, as much as possible, to avoid these. I wanted to support and facilitate successful breastfeeding as much as possible. But the baby's health and safety are always, in every case, the most important things I care about. I have one thing that the urgent care or emergency room physician does not have: continuity. I have the power to ask the parent to bring the baby back the next day, and the day after that. I will see the baby on Saturday and Sunday and July 4th, and so on. I can give parents instructions about what to look for, and if they observe these symptoms or have new concerns, they should call me right away. When they do call, I answer the phone and I know the story, I know them, I know their baby. This concept of continuity of care is extremely valuable because I'm less likely to miss a condition that evolves over time. It saves a lot of money, because I'm not sending every child who's sick in the evening to the ER. And I'm not treating every patient for the first time. I can and do order tests and x-rays, when they're needed. I send kids to the ER sometimes.

But I can see this mother every single day, weigh the baby, try first one idea and if that doesn't work, try another. I can find out how the mother is doing emotionally and physically, how much pain she's in and how tired she is. I can find a way to get that baby on the right track.

There's a nice epilog to the story. We did feed the baby formula, but only for a few days. As the baby put on a little weight from the formula, he got a little stronger with his nursing on the breast, and was less famished when he nursed. Mom's body responded well, and they soon didn't need the formula at all. They successfully nursed for more than a year.

As I pointed out in the original post, formula isn't poison. It's an important tool we have available if we need it.

So I reviewed the baby’s weight history (normal) and recent weight gain (great). The baby wasn’t getting nutrition, not even fluid, from any other source. So that must mean that Amy’s breasts are doing a great and normal job at keeping him healthy and thriving. There’s no evidence of any kind that her body will either suddenly or gradually stop providing the milk it has already proven that it can provide. She understood the logic, but didn’t have a lot of confidence for the future. She asked what would happen if, despite her excellent track record, she just failed to make enough or any.

What indeed, I asked her back. I guided her through this unlikely scenario the way we should plan a fire exit in our homes. First, would she know? She didn’t have confidence that she would, so I asked her how she would find out. She correctly figured that the baby would be hungry. Since her baby was neurologically normal, and since hunger is one of our most primitive and basic drives, the baby would surely let her know if he weren’t getting enough.

She wasn’t debating with me, but my answers gave her the freedom to ask the frightening questions without being judged harshly. What if the baby was crying and she couldn’t tell if it was from hunger and it really was but she didn’t know? OK, how long would you let the baby cry before calling me? She didn’t know exactly, but it was a lot less than a day. She agreed that her healthy baby could go a few hours without eating and still do well. If the baby really were crying inconsolably, I would always want to be called and usually want to see the baby in person. This is all pretty standard stuff, I think. As we went back and forth on this precise topic, however, I happened upon the answer she needed. I hadn’t understood exactly what would break through this until I hit upon it after trying other answers. 3 hours. That was the key, as it turned out. She was glad to get the reassurance, glad to get my commitment to be there if needed, confident in my professional skills and judgment. What she didn’t have was the confidence to trust her own common sense and innate ability to see when the baby has crossed over from fussy to worrisome. She needed an unambiguous border she could look for. If the baby crosses it, she knows exactly what to do. I could see the relief on her face when I said 3 hours. Any time, day or night, for any reason. Hunger, illness, bad weather, it just didn’t matter. If you try everything you know and the baby is crying for 3 hours, call me.

That wasn’t the only breakthrough. Like many new mothers I see, she was anxious about her continued ability to nurse successfully, even though she had been doing it perfectly. There are sometimes reasons that women have to stop, but they aren’t common. Usually, with some support and expert advice, breastfeeding problems can be overcome. But how, she wondered, does she really know that? She has already taken her body places it has never gone. Sure, my experience is optimistic, but that’s based on other women, other babies. This, I admitted, was an excellent point. I don’t push formula, but this is its perfect role. How do we know if 911 will answer when we call? Still, we teach even kids this number. That can of formula can usually sit on the shelf of a kitchen cabinet for a year. It can wait like a silent guardian, hidden behind the stuff you actually use. Nobody but you and your doctor need to know it was ever there. A can might feed a baby for several days or a week, depending on how big they are. But even if never touched until you throw it away when discovering it as you pack up to move, it is working its magic as an effective contingency plan. Depending on the disfavor in which formula is held, it might not be plan B or even C. But the one day when you decide to leave the baby with your mom for a few hours, but a truck got stuck under an overpass and there’s no way to get off the freeway and people are stopped and getting out of their cars, that can will be there.

Next, and I’ve made this point about bicycle helmets, protecting the baby might be a necessity but the safe and thriving baby is nowhere good without you. So taking care of yourself is crucial for the baby’s life and happiness. No, that doesn’t mean I think you should give in to the urge, ever since you heard of that big storm in the Gulf of Alaska, to have a neoprene Snugli custom made so that you'll be prepared when you get the text that Mavericks is up—way up—and you want to show the world how gnarly you really can be. Once the baby’s needs are met, we need to find a way to fold them into our  lives in some functional way, or perhaps fold our lives into theirs. For Amy, this meant getting out of bed, out of the sweatpants and into regular attire and footwear. Another subtle advantage of housecalls, I made this suggestion to help her, not hurt her feelings. Perhaps doctors don't usually make fashion tips, but this was an essential precursor to the final note of this post.

This last is important because it facilitates the next important suggestion I made. She needed to take a walk. I strongly urged her to go for a walk with the baby in a stroller every day, without exception. Every part of this idea has a reason behind it. The feedback I've received has been so consistently good about it that it seems inexplicable for it never being mentioned in my training or textbooks.

The walk allows the new mother to get some exercise. Since this is often after spending at least a few days in bed, even previously fit mothers should take it easy at first. And for goodness sake, check with your OB who may have information about your stitches that I just don't. Studies have clearly shown that even a couple of days in bed decrease our fitness level. Together with some blood loss, you need to get back on your feet. Studies have also consistently shown that exercise improves our mood. People who get some exercise every day tend to sleep better, and some important functions of their body seem to work better. These include breathing and digestion.

The walk allows the mother to get some daylight. Amy hadn't left her bedroom much since leaving the hospital. Her planning for the baby had been so good, in fact, that her room had a changing table and baby supplies, a crib, swing, and so on. I noted this as her mood gradually lifted, and inquired when she planned to start using empty tissue boxes as slippers as Howard Hughes apparently did when he sealed himself in the penthouse of a casino he owned. Just because she was suffering didn't mean I couldn't make fun of her. Daylight, too, has been demonstrated to lift the mood and help regulate sleep.

Daylight is also helpful for the baby. It is directly therapeutic for jaundice, which baby Henry didn't have. But the baby had been living in a dark cave for 9 months. It needs daylight exposure (not direct sun, just daylight) to establish a day/night pattern. It also needs daylight to help provide vitamin D, which is activated by sunlight.

I specified using a stroller for several reasons. The jostling of the stroller is a natural pacifier, which many babies find soothing. Slings of many kinds can be great when doing many activities, especially in places with a lot of other people around, such as supermarkets. But the stroller takes the weight off. There's no extra weight on your back, no extra weight on your hips and knees and ankles. That will make the walk just a little easier, and make you able to walk a little bit longer than you might be able to with a sling or backpack carrier. It also gives you the luxury of stopping. If the baby's asleep, you could stop at a park bench. The stroller also moves the baby away from your body. This seems counterintuitive, since I certainly want you to hold and love your baby pretty much constantly. But it brings up the timing issue.

Take the daily walk at the baby's fussiest time. If your baby is consistently fussy in the late afternoon, say between 4:00 and 7:00PM, that's the time to go out. There aren't too many things more frustrating than trying and failing to comfort a fussy baby. It makes us feel helpless and doubt our ability to parent. But if the baby's basic needs are being met, and we know he'll be fussy in the late afternoon, that's the time he'll benefit from the calming effect of that walk in the stroller. If it's his fussiest time, he won't be right in your face, reminding you of your shortcomings as a parent. That, after all, is what adolescence is for.