Seventh Kid

This past week my older son has been unwell with a fever but no other symptoms.  Maybe he had a mild cough but otherwise seemed okay.  A few nights found him coming into our room and the heat raging of him indicated to me he’d had a fever.  The inevitable phone call from the school telling us that he was sick came and he ended up staying home just one day and actually seemed pretty good that day except for not having much of an appetite.

So imagine my surprise when I go to pick him up from school the other day and his teacher (who knows that I am a physician) tells me that six children are away with strep throat.  Six!  I thank her for the information and immediately turn to my son, take out my phone, turn the flashlight on and look in his throat.

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The white spots on his tonsils are pus, or exudate. Probably from a strep infection.  He hadn’t had much of a fever in 24 hours so I decided to wait to get him tested.  This morning he woke up with no fever, but complained of his tummy hurting every time he tried to eat something.  Husband and I wondered if it was his throat that was actually causing him pain.  Kids are kind of dumb when it comes to being able to tell you where it hurts, I find.

Anyway, husband worried that our son had already had the infection for a few days and would be more susceptible to complications (post-streptococcus auto-immune diseases) so I took him to my office in the hopes of getting a rapid strep culture done.

Now, it’s hard enough to take a throat swab for a 4.5 year-old patient in the office, imagine trying to do it on your own son? I had to bribe him with a cookie his grandmother made.  When he saw the how long the “Q-tip” swab was he panicked and covered his mouth.  I told him it would be really fast and that we had to do it or he wouldn’t get the cookie.  “Oh fine,” he said.  So he opened his mouth and I was able to get a really, really, really quick swab of that tonsil.  After lots of crying and “Ow! Mommy, that hurt!” there was no way he was going to comply again.  Looking at the swab, I could see I had gotten a bit of that junk off, so I proceeded with the test.

The rapid strep kit really helpful in the office.  Normally a throat swab takes 48 hours to get results.  With these rapid kits I can have an answer in 5 minutes. I also really like doing them because it’s like a little science experiment I can do right in the office!  It definitely makes a typical day more interesting.

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Very much like a pregnancy test, one line is negative for strep and two lines is positive.

My son’s test had a very faint second line.  Given the history of six other children in his class with strep infections, his on and off again fever, lethargy and lack of appetite, not to mention the tonsils looking the way they did, I elected to treat him.  Yes, I should have taken him to his own pediatrician but I didn’t.  After a couple of doses of Amoxicillin, he is already looking better.

Sometimes it’s really convenient being a doctor mom.

Playground Strikes Again. 

I received a text from husband this afternoon. 

“She fell off parallel bars and dislocated her elbow. I popped it back in. Going to emerg.” 

I promptly left the office before my last patient arrived and met them at the ER.  

Deja vu. 

Elbow swollen. At first I thought she suffered a pulled elbow but husband says she landed on an outstretched arm. The same arm she broke 9 months ago. 

Sigh. 

Thankfully the ER  was pretty quiet. We were triaged, seen, x-rayed and casted within two hours. 

While there was no obvious fracture seen her X-ray showed a class “sail sign” which in children is suggestive of a supracondylar fracture.  Leave it to my kid to have a textbook xray. 


She’s in a cast/splint until our next visit to the fracture clinic where they will re- xray her and see where things are at. She’s already decided she wants a pink cast this time. 

Kids.  

An Unexpected Gesture

I have several families in my practice who have delayed vaccinating their children.  (Don’t get me started!)

One such family came in today for the final vaccination of the childhood series.  The little boy is 4 years old and he was receiving his second dose of MMR and varicella (conveniently packaged in a single dose vaccine called MMRV).  He was a little scared, of course and asked me a question as I was preparing the vaccine.

“Can you put it right here?”

I turned to look at him as he pointed to the inside aspect of his forearm.

“Well, the needle has to go in the fatty bit of your arm and there isn’t enough fat there.  How about we put it up higher on the back of your arm?”

He agreed with a nod of his head.

I cleaned the back of his arm with a swab of alcohol and gave him the needle. There was not a whimper.  He took it like a man.

As I was back at the desk, finishing up the clinical note and completing his immunization record he walked over to me and said “Thank you, Doctor” and gave me a hug.

A hug! For giving him a vaccine.

Well, I’ll be damned.  He just made my day.

Higgledy Piggledy

Higgledy piggledy
Wiggledy wump,
I met a man
Who caught a mump:
With his left cheek lumpy
And his right cheek bumpy –
Higgledy piggledy
Wiggledy wump.

Higgledy piggledy
Sniggledy sneezle,
I met a man
Who caught a measle:
With his chest all dots
And his face all spots –
Higgledgy piggledy
Sniggledy sneezle.
– Alligator Pie, Dennis Lee, 1939

I read this book to the kids the other night.  My daughter loves the illustrations and this one in particular.  She asked me what a mump and measle was.  I explained that they were illnesses caused by germs (viruses) but that most of us don’t get them anymore because of vaccines. She kind of understands what vaccines are, I explained how it’s a needle that she gets that protects her from illnesses like the one described in the story.  She seemed satisfied with that, so we continued reading the book.

But my mind stayed on Higgledy Piggledy, primarily because of the news recently.  There have been outbreaks of measles in a few Canadian cities, mostly in communities where the vaccination rates are frighteningly low.  In the nation’s capital, Ottawa, a young boy contracted measles after returning from the Philippines, a trip he took with his parents.  The child wasn’t vaccinated.  Upon returning home, he became ill and went to not one, not two, but three different walk-in clinics (including an emergency room) before getting diagnosed. Meanwhile, the child was infecting his classmates at school, not to mention a potentially vulnerable population in the ER.  Within a few weeks, another four cases were confirmed.  Another outbreak is also happening in British Columbia.

I’ve written a lot about vaccines.  I’m not going to belabor the point, I believe vaccines work and I believe they are safe.  I don’t believe they cause autism and I believe that, in the end, after all is said and done, vaccines save lives.

Back in 1939, Dennis Lee was born. Decades later he wrote a poem about mumps and measles.  He likely had the illnesses as a child.  He probably recovered.  Not everyone he knew would have been that lucky.

Please vaccinate your children.

My Chunky Monkey.

My 6 month old just got his vaccine yesterday. He weighed in at a whopping 18 lbs 6.5 oz.   Two months ago he was just under 14 lbs.  Talk about weight gain!!

Ah, the marvels of formula.

Pediatrician noted the huge jump in weight and asked what changed.  I explained the transition to formula and then the next question was about his sleep. He has been still consistently getting up around 2-3am and then again at 5-6am.  This is after going to sleep around 6pm, sleeping for 5-6 hours, then waking for a feed before husband and I turn in for the night.  He is also now consistently taking solids (mainly just a mixed cereal now).  She suggested that the 2-3am wake up probably isn’t related to hunger and we should try to let him cry it out.  Alternatively, we could try the dream feed.

I’d heard about this dream feed from a friend of mine several years ago, but never needed it for the first two kids.  Both had started sleeping through the night well before I returned to work (the first at 4 months of age, the second at 5 months of age).  With less than two weeks to go, I really need this little man to start sleeping longer.

So, last night, I woke him up at 10:30pm and he drank 4-5 oz of formula.  He fell back asleep pretty quickly after that, (and so did I), and didn’t wake again until 5am.

WIN!!!!

Fingers crossed this keeps up for the next 13 sleeps.

“What did you say? I can’t hear you!”

Day 8 – January Daily Blog Posting month

I almost blew my daily blog challenge!! I write today’s post from my phone as I struggle to stay awake.

Today was a busy day. I spent the morning at the office getting our receptionist’s new computer up and running. Thank goodness husband decided to stick around. I ran into a bit of trouble getting a piece of hardware to install but he came to my rescue.

Daughter had a doctors’s appointment this afternoon, a follow up for an ear infection she had over the holidays. She’s been complaining of pain in her ears and appears to be having issues with her hearing. She is always asking us to repeat what we are saying, and is constantly saying “What?”. Husband was concerned about her hearing so off we went to her doctor. Turns out she just has a lot of fluid buildup from the infection and it needs time to drain. In the meantime it looks like we will have to speak more loudly around her.

I wonder how long it will take for her to figure out she can just ignore us and pretend it’s still her ear causing the problem? Are five-year-olds that smart? I think mine might be.

Poop.

Day 23. National Blog Posting Month.

Poop.  Oh yeah, I’m going there.

The baby is exclusively breast fed.  He’s gaining weight pretty well (we just had his 2 month well-baby visit and is just shy of 11 lbs), he’s smiling now and watching everything that is going on around him.

The only thing he is not doing regularly …  you guessed it, pooping.

I think the last time he had a good poop was over a week ago.  It might even be 10 days, I’m not sure. In my sleep-deprived state, I’m not even sure what day it is!

You should have seen the horrified look on my mother’s face when I told her.

“Let’s give him an enema,” she said, seriously.

“Um, yeah, mom, no.”

Never have I been so obsessed with bowel movements than when I started having kids.  It starts with that first bowel movement after birth – meconium.  It reveals so much about the infant’s gastrointestinal system.  When it happens, it’s like everyone breathes a sigh of relief.  If it doesn’t – alarm bells sound.

If the infant is breastfed, then over the next 5-7 days the poop changes colour from the tarry black of meconium to the lovely shades of green to yellow.  An exclusively breastfed baby will have liquidy, yellow seedy poop.  (Feel free to Google for an image.)  Most breastfed infants, in the first month of life, will have a bowel movement several times a day.  By two months of age, babies may not poop for a week, sometimes up to 10 days, and this is still considered quite normal, so long as he is nursing well and gaining weight. [http://www.webmd.com/parenting/baby/the-scoop-on-baby-poop]

So, nothing to worry about, right?

Right?

Ugh. I really just want him to have one of these:

The pooplosion.

Is that too much to ask?

Keep It Loud!

Day 10.

An interesting article came across my Twitter feed yesterday.  I follow ScienceNews and yesterday, this article popped up:  “Too little noise is bad for newborns.”

Before I had kids, a friend of mine had twins.  I remember she emailed me from the local Starbucks when the twins were a few weeks old.  I couldn’t believe she was out and about already, nevermind at a coffee shop!  She said something to the effect that her kids were adapting to her lifestyle, not the other way around.  I wondered about the noise and whether they could sleep.  She said the noise actually helped them sleep better!

Growing up, I didn’t have a lot of exposure to infants and children.  My husband, on the other hand, did. At the age of 12 he was changing his nephew’s diapers.  He remembers his mother always saying how it should be quiet when the baby’s sleep.  When we had our firstborn, she spent the first few weeks of her life swaddled in a bassinet while we watched The Lord of the Rings Trilogy and struggled to stay awake during her feeds. [My husband was such a trooper, staying with me at nighttime for those first few weeks.]

I digress.  My point being that in order to stay relatively sane, we made a point to keep up our normal lifestyle, including the noise factor, in our household.  There was no “Shhh–ssshing” when she napped.  Instinctively we believed that our kids should learn to sleep with some normal amount of household noise.  We were lucky in the sense that our kids were pretty adaptable.  We could take them with us anywhere, really.  We slept over at friend’s places and brought the kids with us.  They were portable.  But more importantly, we never needed their environment to be super quiet for them to sleep.

Which is precisely why the article I mentioned above peaked my interest.

NICUs are loud – there are numerous machines beeping, whirring, all working to keep those little people alive, and lets not forget all the talking going on between the nurses, doctors, and parents.  A few years ago, an American Academy of Pediatrics analysis suggested that all this noise actually exceeds acceptable levels (45 dBA).  In response to this, many NICUs started moving away from open wards to private rooms for these little lives. Private rooms led to quieter rooms.  This should be better for them, right?

Researchers at Washington University School of Medicine in St. Louis, studied the effects of noise, and lack thereof, on 136 preterm infants. The preterm infants (< 30 weeks gestational age) were assigned to either a ward room or private room.  The primary outcome was developmental performance at 2 years of age. What they found was surprising.  By the time they left the hospital, babies who stayed in private rooms had less mature brains than those who stayed in an open ward. And two years later, babies who had stayed in private rooms performed worse on language tests. ScienceNews summed it up better than I can:

The researchers believe that the noise abatement effort made things too quiet for these babies. As distressing data from Romanian orphanages highlights, babies need stimulation to thrive. Children who grew up essentially staring at white walls with little contact from caregivers develop serious brain and behavioral problems, heartbreaking results from the Bucharest Early Intervention Project show. Hearing language early in life, even before birth, might be a crucial step in learning to talk later. And babies tucked away in private rooms might be missing out on some good stimulation.

The study took place at the urban St. Louis Children’s Hospital. The parents of these 136 babies visited their babies for an average of 19 hours a week, which means that many of these babies spent a lot of time alone. Babies in private rooms might do just as well as — or better than —babies in open wards if parents were around more to talk, sing and snuggle.

Obviously more studies need to be done to figure out how best to nurture and care for these early arrivals, but it did reinforce for me one simple thing – the noisier the house, the better.

So tell me, parents, how noisy are you around your infants?

30 g/day

No, I’m not talking about how much fiber one should have in a day – though, 30 g is about right, I think.  I’m referring to the amount of weight a newborn should gain per day during the first few months of life.

For my American readers – 30 grams = 1 oz.

30g/day was drilled into my head in medical school and particularly so in my Family Medicine training program.  A newborn will typically lose about 10% of his/her birth weight in the first few days of life, but usually by a week of age, the majority of infants will have regained the weight.  I was also taught that this should occur within the first 7 days of life.

So, in my first few years of family practice, I was quite diligent about these milestones.  If a baby hadn’t gotten back to birth weight within a week or wasn’t gaining that magical 30g/day, I would refer to the pediatricians across the hall from my office.  After a few of these referrals, the pediatrician walked over to my office to have a little “chat”.  She’s a lovely woman (she actually sees all my children) who sat me down and told me, that while she appreciated all the consults I was sending her way,  all of the infants were healthy and I was jumping the gun on the referrals.  I explained my reasoning, and she basically told me that “in the real world of clinical practice, most infants will regain their birth weight within 2-3 weeks, and so long as they are gaining weight, don’t focus on the 30g/day rule.”  She reminded me it was more important to assess how the mother was nursing, or how much formula was being given; she reminded me that the hydration status of the infant was more important than the number of grams gained.  Clinically, how does the infant look?  Was the infant having adequate numbers of wet diapers during the day? etc.  It was amazing advice and (sadly for her), my referrals drastically declined.

Yet, when it comes to my own child, I am stuck on that 30g/day rule.  Perhaps it’s because, with my first-born, I had a pathetic milk supply and didn’t recognize that my daughter was hungry and losing weight.  By the time she was 2 weeks old, she had lost about 20% of her birth weight, was just getting enough milk to stay hydrated, but not enough to gain weight.  I had to start supplementing with formula and watching her guzzle back that first 4 oz of formula in about 20 seconds made me realize just how hungry she was.  Cue the gut-wrenching mommy guilt.

I didn’t have to supplement with my second child – we had a great nursing relationship and he gained weight well.  Now, with the third. it seems to be following the same pattern, yet today I decided to take the baby to my office for a weight check only to discover that he’s gaining only about 15 oz/ day.

Cue the mommy guilt again. Oh God, do I not have enough milk for him?  Is he hungry and I’m just not clueing in?  Should I be waking him every 2 hours?  When I relayed my concerns to my husband, he just looked at me and said “He’s fine.”  He’s pooping and peeing appropriately.  He seems satisfied at the breast (unlike the firstborn who was clearly frustrated after a few minutes on the breast).  I am being way too hard on myself, yet I just can’t help it. And to top it all off, the baby now has the cold his older siblings have.

Did I mention he’s only 3 weeks old?

FML.