Tired II

There were so many interesting comments on my previous "Tired" post, and enough controversy generated by it, that I thought I'd go over some of the issues again - and defend myself, although most commenters were remarkably polite.

The consensus opinion seems to be that sleep should not have a role in our decision whether or not to stop life support. As smartblkwoman said, "it is very cruel to weigh someone's death by how much sleep you can get." I absolutely agree, and that is why I try my hardest to not let my desire for sleep affect my decision about termination of life support. Most of the time I'm successful. As Dianne said, my hope is that I'm "able to make better decisions knowing that that motivation is there."

But it brings up the more general problem of a physician's personal needs or desires affecting his or her medical decisions. For example, an obstetrician has tickets to a concert in two hours. Does that affect his decision whether to do a caesarean section in a woman who's poking along in labor, versus letting her labor longer? Or a pediatrician wants to be home in time for her son's birthday party, and she has two more patients to see. Does that make her rush through those patients faster than she normally would? A good physician doesn't let his or her personal life affect medical decision making, but we're kidding ourselves if we think there isn't at least a potential problem there.

Commenters also opined that a physician should not be able to unilaterally decide to stop life support and needs to discuss it with the parents. I agree with that, too. My paragraph addressing that issue said "sometimes" I wish we could stop the ventilator on our own. Most of the time I realize that would not be a good thing, that there would be too much potential for abuse by some physicians. Having parents agree is a check and balance in the system. (Sometimes, too, before withdrawing the ventilator I'll ask the nursing staff if they agree with stopping support.) I think, though, that the worry about causing the parents guilt by making them say it's okay to stop the ventilator is a legitimate concern.

These end of life issues are tough. If they're not tough for you, maybe you shouldn't be making them.

Tired

I think most neonatologists would recognize this scenario. A baby is born very prematurely, say 23 weeks give or take a few days, and is placed on a ventilator. He does poorly, and after several hours, at about 2 a.m., it becomes apparent that he will not survive. His blood gases (measures of the oxygen and carbon dioxide in the blood) are terrible, in spite of multiple ventilator manipulations, and his fluid status is getting out of whack too. He was simply born too early, and no amount of intervention can save him.

In these situations I will usually go to the parents and apprise them of the situation. We can continue ventilating the baby full bore, until his heart finally gives out in several hours, or we can stop the ventilator and let the parents hold him, often in a private room. Death comes more quickly then. I usually recommend stopping life support, and speak about letting him die with dignity. Sometimes parents will do that, but other times they cannot bear to give permission to stop the ventilator.

Now, I truly believe it is better to just stop the ventilator in these cases, and that continuing to pound the lungs with the ventilator until the bitter end does no one much good. And I do believe in death with dignity, and that it is better for the parents to be able to hold their baby and simply be a family, even if it is for a short time. But the real reason I want to stop the ventilator is so the baby will die more quickly and I can get some sleep.

I'm pretty sure it sounds petty or selfish of me to be thinking of a few extra hours of sleep, when a baby is dying and a family undergoing a life changing event. But I can't help it. I spend about six nights a month on call in the hospital, and if I'm up all night I'm tired for days afterwards. If I can get some sleep when I'm on call it's not so bad, and it seems really annoying to miss sleep when you know you're just continuing to ventilate a baby everyone knows will die anyway. It's not that I have ill will towards the parents or anything. I just get tired of being tired.

Sometimes I think the best solution would be for neonatologists to be able to stop the ventilator in these situations without the parents' permission. It would avoid making the parents feel guilty about turning off their baby's life support; it would let the baby die with at least a small modicum of dignity; and it would let me get my sleep. It sounds like a win-win situation to me, but I don't think it's going to happen in this country.

P.S. My apologies for not posting a post on Saturday. I was out of town for the holiday weekend, and the wireless hot spot I thought I could use wasn't working.

Drugs

A drug that we use in the NICU for pain relief, fentanyl, is in the news. Allow me to stray from neonatal topics for a day.

Fentanyl is a powerful narcotic, about 80 times more potent than morphine. In some large cities in the U.S., such as New York, Philadelphia, Detroit, and Chicago, drug dealers are mixing their heroin or cocaine with fentanyl. It isn't clear why, but it might be to give a better or different high. Unfortunately, the combination can be deadly, and several people have died as a result of using the combination. This is, of course, terrible. But what caught my eye was the reaction of some family members of the deceased drug users. They were blaming the police for the deaths, saying that the police did not put out warnings soon enough that the lethal combination was on the streets. Doggone those nutty police, can't they get anything right? All we're asking is that they ensure the safety of the local illicit drug supply.

In a related story, capital punishment by lethal injection is gathering some criticism for perhaps being cruel and unusual punishment, because in some cases the punishees were given too small a dose of the drugs and may have suffered during the lethal injection procedure. Now, I'm not a fan of capital punishment, but that's a topic for some other time. What I can't figure out is why someone would ever be underdosed when undergoing lethal injection.

I am by no means an expert on lethal injection , but I understand that a combination of three drugs is given. First, a powerful analgesic and/or sedative is given, something like fentanyl, although I think they use another, similar drug for this part. Then a drug that paralyzes the person's muscles is given, to avoid having any thrashing, I guess. Finally, something like potassium chloride is given to stop the heart. Apparently, when some cases have been audited, there was concern that too small a dose of the first drug was given, leading to the person being awake and aware when the potassium chloride was given. But it's hard to know for sure, because the person is paralyzed and cannot speak or otherwise show pain or discomfort.

Here's the thing. The only reason to underdose with a drug like fentanyl is to avoid having a complication, such as respiratory depression, that could lead to death. But in the case of lethal injection, that's not really a consideration, is it, because you're killing the guy anyway. So give him (or her) a huge dose of the analgesic/sedative, one that leaves no doubt that the person is knocked out. What's the worse that can happen if you give too big a dose? The person might die?

You can't make this stuff up. It's just too crazy.

P.S. Erratum: A couple of posts ago I mentioned a six year old patient who weighed 160 pounds. My pediatrician friend, whose patient it is, told me the other day that she had been mistaken. He really weighed only 112 pounds. Sorry for the error.

Why

On Saturday there were three admissions in a row to the NICU. One was the first child of a 17 year old, one the third child of an 18 year old, and one the sixth child of a 23 year old. I've written about single mothers before, but this prompts me to think of them again, and wonder why they become single mothers.

I can understand a young woman having one unplanned baby. I suspect that many teen moms just didn't take birth control seriously or thought it couldn't happen to them, but I doubt that's true for all single moms, and it doesn't explain the young single mothers with two or more children. As smartblkwoman said in a comment on my last post, "I cannot fathom anyone having more than one accidental pregnancy."

I read an article a couple of years ago that reviewed a book about single mothers. (The name of the book escapes me.) The authors of that book thought that the reason for many single woman pregnancies was so the mothers could reconcile with their family. The authors stated that no matter how bad the relationship was, no matter what the young woman had done to tick off her family, when she had a baby all (or almost all) was forgiven; the birth was celebrated and the young mother welcomed back into the family's good graces. Her social standing in the family took on a different status.

Others have said that young single women have babies because they want someone to have as their own and love them. More cynical people claim mothers have kids for the support checks they get from the state for them. And I suppose that there are some women who just don't think about it. They have sex, get pregnant and have babies. It's just the way life goes.

There is probably some truth in all of the above, but I doubt that we can give one reason that fits all single moms. They are a varied bunch, like any other group of people. But I have to believe that a society that no longer sees anything wrong with single parenthood, that indeed even expects single parenthood, without any thought of social stigma, is a big factor in the phenomenon. I don't want to vilify single mothers, or not support them or their children, but somehow we have to do that while also sending the message that two parent homes are the better way to go.

On Saturday I also admitted a premature baby whose single mother was twenty years old. It was her second pregnancy, with the first ending in a stillbirth. The maternal grandmother of the baby told me how important this pregnancy was to the mother, how important it was to successfully deliver, for her self confidence and feeling of well being. I thought I was going to gag.

And we haven't even begun to talk about the fathers of these kids.

P.S. Check out a new Grand Rounds at Parallel Universes.

Worry

I worry sometimes. I worry whether the jaundiced baby's mother will bring her back for a jaundice level check the next day. I worry whether I should have just kept the baby here. I worry about the 24 weeker who's been on a ventilator for 10 weeks now and is still on fairly high settings. Will we be able to get him off the ventilator, or will he need a tracheostomy and long term ventilation? And will his 19 year old mom be able to handle it? I worry about the small baby we just discharged who is feeding okay but not great. Will he eat well enough? Will his mom make an appointment with the pediatrician in 4 days for a weight check like we asked? I worry about one of my partners, who still makes some statements about fluids that suggest he doesn't understand some pretty basic principles of fluid management , even though he's been a practicing neonatologist for many years. But most of all, I worry when I've done everything I can for a baby and he's still doing poorly.

Actually, I don't worry as much as I used to. Earlier in my career, if a baby was not doing well, I would wonder what I might have done wrong. Now, after more experience, I realize that if a baby is not doing well after I've done everything I can think of, it's more likely because he's very sick and nobody can make him better, and not because I've screwed up. Now, I don't worry as much as I used to, but I still think and wonder about things.

I think about the mother whose delivery I just went to, who's 23 years old and just had her fifth baby, and who weighs 370 pounds. I wonder how long she'll live, and when she'll start having knee and back pain, and how big her kids will be when they're 23 years old. I think about the 6 year old patient of a pediatrician friend of mine, who weighs 160 pounds already. I think about the 17 year old who just delivered her first baby. Will she have five babies by the time whe's 23 years old? And then I think about the 18 year old who just had her third baby.

Sometimes I worry I think too much....

Irrational

Mom delivered at about 3 a.m. I was called to the delivery because there was some meconium (bowel movement) in the fluid around the baby, but she did fine. I briefly reviewed the mother's history, and there was something about it - maybe her age of 43 years and the fact that this was her thirteenth pregnancy - that made me ask my screening question. "Do your other kids live with you?"

"No, they live with their father." Bingo. They were placed in the dad's custody by Protective Services (P.S.) It's our hospital's policy to put a baby into the special care nursery instead of the mom's room if there is a referral to P.S., to avoid attempted abductions like the one we had last week. But this was her first baby in 12 years, meaning the other kids were taken away a long time ago, and she had three negative urine drug screens, and I just didn't have the heart to take her baby away from her, and let her stay in mom's room. The social worker gave me a little grief about it the next morning, when we moved the baby to special care, but hey, I don't always make my best decisions at 3 a.m., and frankly, the father of this baby was a really big guy.

It turns out that mom has syphilis, not treated in this pregnancy, so we have to treat the baby with antibiotics for ten days and do a spinal tap on the baby to make sure she doesn't have syphilis in her central nervous system. Mom was not happy when she heard this, and at first refused to give consent for treatment or the spinal tap. By the time I talked to her - my partner had tried first - she had consented to treatment but was adamant about not doing the spinal tap. I tried to reason with her but she was downright irrational, more than just the normal apprehension a parent understandably would have about all this. She said nobody explained anything to her, but when I started to do so, she cut me off after half a sentence. She accused us of experimenting on her baby. She said she was going to see her own doctor that day. I asked her who that was; she paused, then said, "He's an excellent doctor, and after I see him, then I'll let you know who he is." I then spoke with the dad, who said they would come to the hospital - mom had already been discharged - and discuss it further with us. By the time I left two hours later, they hadn't shown up yet.

I find myself hoping that P.S. won't send the baby to her but to foster care instead, because she really didn't seem normal. It's a terrible thing to hope for, in a way, but it's mothers like this that make us a little paternalistic towards our patients sometimes. My frustration with her is mixed with some sympathy, though, because I suspect she might be mentally ill. Parents: some can be so great, others just downright awful.

P.S. Say "hey" to Carrie at Neonursechic, a fairly new entry into the blogosphere.

Gender

The middle aged nurse was fanning herself furiously while two colleagues commiserated with her about hot flashes. I was the lone male within ear shot and pretty soon they were telling me how unfair it was that women had to go through menopause and men didn't. This soon led to a discussion of who had it better in life, men or women. "Men don't have to breast feed," they said. "Men don't get to breast feed," I countered. They also thought it unfair that men could father children until they were a very late age, unlike women. That's true, although I'm not always sure it's an advantage.

I was reminded of a conversation I had in high school with a female friend. Somehow we too were discussing the relative advantages of being male versus female. When I asked her if she would rather be a guy, she said, "Oh no! Guys have to worry about the draft and a career and things like that." Okay, maybe she wasn't the most liberated woman I have ever met, but there was some truth in her statement. On my eighteenth birthday, I had to register for the draft, something none of my female classmates had to do. And it was pretty much only guys - and their significant others - who were glued to the TV screen one night a year waiting to see what their draft lottery number would be, a number that would basically determine whether they were sent to Vietnam or not.

On the other hand, I admit that there have been many times in a delivery room, as we waited for a mother to deliver and heard her cries while in the throes of labor, that I have said to the nurse with me, "I am so glad I'm not a woman." And I am, especially at those times. Let's face it, it just doesn't seem right that a seven pound little being can come through that thing it comes through.

One thing is for sure, though. If you're a premature baby, you're better off being a girl. Everything else being equal, premie girls do better than premie boys. I'm not sure why; maybe it's a natural selection thing, because we need more women than men to propogate the species. Whatever the reason, that fact did little to soothe my menopausal friends.

P.S. A new Grand Rounds is up at Doc Around the Clock.

Grief

Two or three years ago we had a baby born with osteogenesis imperfecta, a disease that makes the bones very weak and prone to fractures. There are several varieties of it, and this baby had one of the most severe kinds, so severe that even his movements inside mother were enough to cause him to have many fractures. Theses fractures stunted his growth and caused him to be deformed. When he was born at almost full term he only weighed about three pounds, and his chest and rib cage were so affected that he could not breathe sufficiently on his own. We had placed him on a ventilator at birth, but it was apparent shortly afterwards that this baby's prognosis was dismal, and that he would not survive off the ventilator. This is a painful disease; the baby winced with small movements. We gave him strong pain meds and my partner recommended to the family that we remove the ventilator. The parents seemed shocked, blew up at my partner, and refused to deal with him again.

I was the next neonatologist to speak with the family after a couple of hours and their hostility was almost palpable when I entered the room with the nurse manager to meet them. We had several more conversations over the next two days; their anger resolved and finally they agreed to remove life support. The baby died shortly thereafter.

It turned out that the family had been told that the child likely had a fatal disease several weeks before by a perinatologist, a specialist in high risk pregnancies. I was a little annoyed when I heard that (although you feel guilty being annoyed at a family who just lost a child). Why had they blasted my partner so, when they had been told many weeks ago of the likely course of this baby? They told me they had chosen to not believe the perinatologist and hope for the best.

In retrospect, I can see they were going through the five stages of grieving that Kubler-Ross noted: denial, anger, bargaining, depression, and acceptance. They just had a very long and effective denial phase, and reached the anger stage when my partner reaffirmed the bad news. My partner is excellent with parents; he was just in the wrong place at the wrong time.

I've seen this sort of thing happen before, although usually the family isn't so hard on the doctor. It's appropriate that it takes a little while for the parents to accept that they have to stop life support for their child. It just would have been easier if at least some of that adjustment period had occured during the pregnancy, rather than afterwards.

Pink II

There were so many interesting comments on my Pink post that I couldn't resist making some more comments about drug using mothers and our reactions to them. As I tried to say in the post, I'm not really serious about forcing them to be sterilized, but it does, I think, show the measure of the caregivers' frustration with these moms that they would think of the possibility of sterilizing them. Ariell makes an interesting point, too, about possibly requiring them to get a depo-provera (birth control) shot to get their checks, but as Flea points out, civil liberties are too important in our country, appropriately so.

We don't see many methadone mothers in our hospital because the methadone program for pregnant women in our area is located in a hospital across town. Most of the drug using moms we see are cocaine users. Their kids don't have as bad withdrawal as babies whose mothers used opiates such as heroin or methadone. There is some debate about whether cocaine harms the developing fetus. I haven't exhaustively studied the subject in the last couple of years, but I think that fetuses are relatively unscathed by intrauterine cocaine exposure. When cocaine became the popular drug in the late 80's and early 90's, there were some gloom and doom articles in the popular press saying we would have an epidemic of "crack" babies who would all reach kindergarten at the same time and need special education, putting an unbearable strain on our educational system. That hasn't happened, a testimony to the incredible resilience of the fetus and newborn. By the way, I don't allow residents and students in our NICU to use the term "crack" babies, a derogatory term that pegs them as losers before they even have a chance.

I like to ask the residents, "What is the worst common drug of abuse you can take in pregnancy, in terms of harming the fetus?" Some of them get it right, even though it's a bit of a trick question. The answer is alcohol, the only legal drug of the bunch. Alcohol causes growth and brain retardation and mental deficiency. If you're looking for a good long term outcome, give me a baby of a heroin or cocaine addict any day over that of an alcoholic mom.

In closing, I'd just like to point out a group of people who are probably especially frustrated with drug using moms, and that group is the infertile nurses who work in the NICU. We have two such nurses in our NICU now, both in their mid to late thirties, who have been struggling to have a baby for years. It must drive them crazy to see moms in their early twenties with 4 or 5 kids, and drug using moms with 8 or 9 kids, all dropping babies like rabbits, when they can't even have a single child. My heart goes out to them.

Subjugate

It had been a fairly routine vaginal deliver, performed by an OB resident with a medical student assisting. I'm pretty sure the medical student was new to OB, because I hadn't see him before at deliveries. Apparently a hemostat was missing, and the circulating nurse was asking around for it. "There's one in the bucket," the medical student said. Instead of thanking him, the nurse went off on a bit of a harangue about how it would have been nice if the med student had told her earlier, and the importance of that, and blah, blah, blah....

If a doctor harangued a nurse like that over a small thing, he or she would be appropriately criticized. Doctors, at least some of them, can be labelled as haughty egotists who fly off the handle and really lay into people. Sometimes that criticism is accurate and deserved. However, it's not just doctors in hospitals who can belittle another person. I think it's anyone who has a position of authority over another person.

I remember as a medical student being scolded by nurses; scrub nurses in the operating room come especially to mind. My first month in the NICU as a resident was no picnic, either. It's a strange new environment, and although most of the nurses were pretty nice and understanding, there were some who used their familiarity with things and our unfamiliarity to give us a hard time and make us feel ignorant. Also, I worked as an orderly during summers in college. Trust me, nurses can be just as snippy and hard on orderlies as doctors can be to nurses.

So if you're not a physician and get disgusted when you see one acting like a pompous ass, think twice about how you would act towards a person subjugate to you in the same situation. Although we don't condone it, probably most of us at one time or another have been hard on someone lower than us on the social totem pole at work. Doctors just happen to be higher on that totem pole than most people. That's not justification for bad behavior, of course, but perhaps might give us pause before we're too critical.

Pink

We had a code pink yesterday, which is the code called overhead when someone tries to abduct a baby. A mother had delivered a full term baby in the morning and no one apparently knew that earlier in her pregnancy she had tested positive for cocaine. This morning the social worker noticed that her current urine drug test showed opiates - a class of drugs that includes heroin, methadone, codeine, etc.- and informed her that her baby would have to stay at the hospital after mother went home until Protective Services checked things out. A few minutes later the social worker saw mother with her coat on and asked her where she was going. She then noticed the baby tucked in mother's coat. The mother took off down the hall, the social worker called a code pink, and the chase was on.

The mother made it through a door that is usually locked - someone had just come through it - and down a back stairway. She came out on a medical ward, punched a nurse in the jaw who tried to stop her, and headed down the stairs again. She was finally caught on the first floor in the radiology department. Her visiting privileges were revoked.

As we see in so many drug users, mother was a near "grand multip." This was her eighth pregnancy and sixth baby. None of her other children are in her custody. I don't really know what to think about her. In a way I feel sorry for her, because of her drug habit and strong unfulfilled desire to have her baby. On the other hand, I just wish she would stop having babies. Although no one said it this time, often people when confronted with a drug user having her umpteenth baby will say a comment to the effect that it's too bad we can't force such people to be sterilized. And I know how they feel. I don't want to become like China with its forced sterilizations and abortions, and am not seriously proposing that, but can't we do something to stop these people from having more babies?

I guess not.

P.S. Grand Rounds is up this week at Aetiology, and a new Pediatric Grand Rounds is at Unintelligent Design.

Heavy

We recently had a 400 pound woman deliver a baby. She needed a caesarean section, and they had to do it in the surgery suite used for bariatric (weight loss) surgery rather than the C-section room of labor and delivery because she was so heavy she would have broken the bed in the C-section room. The anesthesiologists and obstetricians were pretty worried, because obesity to that degree increases both the obstetric and anesthetic risks, but mother and baby did fine.

I was reminded of that delivery because of the recent news about the agreement to limit the sale of soft drinks in schools - a long overdue agreement, in my opinion. It's no secret that obesity is a major problem in America and some other developed countries, and anything that can combat it is good news to me.

I should confess that being overweight has never been a problem for me, so perhaps I have no business commenting on obesity. I know that it is a life long struggle for many people, and I feel sorry for them, because of their struggle, their increased health risks, and their being the object of many unkind jokes. On the other hand, there is a strong history of heart disease in my family, so I follow pretty religiously a low fat diet and know the difficulties and temptations of doing so. I haven't ordered french fries and similar foods in a couple of years, and even though I love ice cream, I'll only eat the fat free and low fat stuff; so it annoys me a bit when I see some pretty large people frequently order wing dings and fries, or a double cheeseburger, in our hospital cafeteria.

Oh well, I guess it's a personal thing, although there was a presentation at the conference I recently attended that showed that not only did infants of diabetic mothers have more problems than normal babies, something we've known for a long time, but infants of obese mothers had more problems too. And it's too bad that the current younger generation might be the first generation in centuries to have a lower life expectancy than their parents - all because of obesity.

Observation

The nurse asked me to come right away to the NICU. I arrived to find one of our smallest babies in trouble, with formula coming out of his mouth, his heart rate and blood oxygen level both about half of what they should be, and various monitor alarms adding sound effects to a scene of seeming chaos. The nurses were trying to suction his mouth and endotracheal tube - the tube that goes through his mouth into his windpipe and is connected to the ventilator - but not having much success. The mother observed the scene from a few feet away, tears running down her cheeks. One of the nurses asked me if I wanted the mother to leave; I indicated it didn't matter to me.

We ended up removing the endotraheal tube, getting his mouth well suctioned out, and breathing for him briefly with a bag and mask. As soon as we did so, his heart rate and oxygen level improved. By this time, though, mother was sobbing and gasping, and soon thereafter left sounding like she was about to vomit. We then replaced the endotracheal tube and the baby stabilized and did well for the rest of the night. When mother returned, we tried to reassure her that her baby was now doing okay and that what she had witnesssed was a typical scene in an NICU - which is true, but of small comfort to a mother who has to see her baby in such distress, even if it is for a brief time.

I'm not sure how much to let parents observe in the NICU. In general, I'm in favor of them seeing a lot. It's good for them, in many ways, to see us all working together for the benefit of their baby and to have as complete and honest information as possible. I also like them to be at the bedside when we're rounding, so they can hear the plan and understand some of the problems with which we're dealing. But there is a limit. Some procedures parents shouldn't have to see done to their child, not because we're doing bad things, but simply because it's too much trauma for a parent to observe. For instance, when we place an endotracheal tube, we put an instrument called a laryngoscope into the mouth and sort of pry the throat forward, so we can see to place the tube. Although pretty safe in the hands of an experienced person, it looks horrible, and I certainly would have trouble watching that done to my own kids.

A few weeks ago a mother asked me if she could watch me do a spinal tap on her child. I said okay, but that I didn't recommend it, and she ended up taking my advice. I can understand why parents want to be present, and we let them observe us starting IV's and drawing blood. But for some other things, like spinal taps and intubations, I'm not sure it's good. For one thing, a parent observing could make the operator more nervous, lessening the chances of a successful procedure, but mainly, it's just a difficult thing for a parent to have to see.

It's a tough question. Parents have heard about the problems with medical errors and want to avoid them in their kids. But I don't know if watching procedures is the way to do it.

Knowledge

I just got back from the Pediatric Academic Societies meeting in San Francisco. It was a nice conference, with a good mix of both original research and review presentations. As a younger doc I used to come home from these conferences fired up about all the new and exciting things. Lately, though, I come home from them reminded more about how much we don't know rather than what we do know.

There's some pretty basic stuff we don't know. We don't know, for instance, when to transfuse babies with blood. We don't know whether giving sodium bicarbonate, a relatively common drug, does any good or not. (Well, actually we're pretty sure it doesn't do much good, but we use it anyway.) We don't know how to measure pain very well in premature babies or the best way to treat it. And if and when we do treat it, we don't know if that improves their overall outcome or not. We don't know the best way to treat low blood pressure in premies. We're not sure what the medicines used to treat low blood pressure do to the brain. For that matter, we don't really know what constitutes low blood pressure in the tiny premies, and like pain treatment, we don't know if treating it makes a difference in their long term outcome. I could go on and on about the stuff we don't know.

Sure, we often act like we know. (Parents don't like it if we don't.) For example, I could tell you at what point I treat low blood pressure in a small baby, and how I would treat it, but I'd be kidding both of us if I said I knew it made a difference for the better. Some neonatologists will tell you they do know when to treat low blood pressure and that they know it helps. Physicians with such bravado are probably the scariest docs of all, at least to me.

Don't be too discouraged by this. We've made some tremendous strides in improving the care of neonates. But for every question we've answered, it seems there are a dozen more still to be answered.

P.S. Grand Rounds is up at Polite Dissent.

Nursing

I suspect most of you have heard of the many benefits of breast feeding, so I won't repeat those here. Suffice it to say that it's superiority to formula feeding is well established. Although breast feeding is natural, it frequently takes some instruction to get it going right, or perhaps I should say it can be easily subverted if not handled correctly from the beginning.

I'm disappointed in the way the nurses in our post-partum area support breast feeding. In short, they don't, and it drives me crazy. Bottles of formula are given way too frequently to babies whose mothers wish to breast feed. It's just easier for the staff that way. A mother really has to be proactive herself to keep her baby from having a bottle. It shouldn't be this way.

Many of our mothers, when asked if they are going to breast or bottle feed, say they want to do both. That's understandable; they want to be able to have someone else feed the baby sometimes. But when a mother says she wants to both breast and bottle feed, she needs to be given some education in how to best accomplish that. She needs to be told to first get breast feeding well established by nursing exclusively for 2 or 4 or 6 weeks before introducing a bottle. If a bottle is given from the start along with breast feeding, too often the baby doesn't get going well on the breastfeeding and pretty soon the nursing is stopped. Unfortunately, though, when our nursing staff hear a mother wants to feed both ways, they just give a bottle. Educate people? That takes too much time.

Another thing that yanks my chain is when we have baby in the NICU whose mother wants to breast feed. They are supposed to be given a breast pump as soon as possible after delivery, yet when I go to see them the day after delivery to give an update on their baby, they almost invariably have not yet been given a breast pump. Fortunately, our NICU nursing staff has been very supportive of breast feeding and taken up some of the slack.

I have tried and tried to improve this. The nursing management tells me they are going to give more education about it; it seems to me that maybe they should be giving some disciplinary actions, because we have been talking about this so long. But the neonatologists do not run the well baby nursery in our hospital; the general pediatricians do, and too many of them in our hospital don't seem to care either. (That is by no means true of all general pediatricians.)

A study in Pediatrics a couple of years ago suggested that as much as 30% of the difference in infant mortality rates between whites and blacks could be abrogated if blacks breast fed as much as whites. When I used to work in a suburban hospital where most of the mothers were white, the nurses fiercely supported breast feeding. It was hard to get them to give a baby a bottle. Now, in this hospital where most mothers are black and the need for breast feeding greater, we can't get them to not give a baby a bottle. We've got a long way to go until there's racial equality in this country.