Vol. 88 April 15, 2013 How Do You Feed a Baby in a Patient-Centered World?

hub “Patient-centered medicine” is one of the new buzz words in health care reform. It is second only to “medical home”; the label for the multi-disciplinary team incentivized by governmental reimbursement to use electronic technology to provide the coordinated, individualized primary care that the family doctor used to provide by himself (yes, it was usually a “he” back then).

“Patient-centered medicine” champions joint decision-making between physician and patient. Most illustrative examples of patient-centered medicine given are high cost, high drama events like alternative cancer treatments, cardiac interventions, and even DNR or “keep plugging” choices. The central tenet is that the patient knows best his or her needs, desires, and feelings and medical decisions should consider those as paramount.

  • Pediatricians recommend breast feeding exclusively for at least 6 months, ideally for 12 months. (1)
  • Nearly half of mothers started solids at age 4 months to 6 months so the infant would sleep through the night and/or they would spend less on expensive formula. (2)

How might “patient-centered medicine” sound when it comes to “feeding baby”?
We pick up the conversation near the end of a routine well-baby visit:

PHYSICIAN SITS CLICKING ON A LAPTOP BACK TO BACK WITH THE PARENT WHO IS DIAPERING AND DRESSING HER INFANT ON THE EXAM TABLE.

PHYSICIAN: Leonard is 4 months old so he’s due for his second round of immunizations today. Before we give those, do you have any other questions?

PARENT: He’s not sleeping through the night. I want to start some solid food. Is there any food I should avoid?

PHYSICIAN: Are you still breast feeding?

PARENT: Well…sort of. I went back to work when he was 2 1/2 months old. He gets formula at daycare, and I breast feed him at bedtime.

PHYSICIAN SWIVELS AROUND ON STOOL TO FACE MOTHER.

PHYSICIAN: As I am sure you know, we recommend breast feeding for the first year.

PARENT: R-i-g-ht… well I had to go back to work. Doesn’t breast feeding make him plumper and more likely to be fat as he gets older?

PHYSICIAN: Breast feed babies sometimes look plumper than formula babies, but we think breast feeding actually protects them from adult obesity.

PARENT: Really? I heard on Fox News last month that breast feeding didn’t actually do that. (3)

PHYSICIAN: Yes, that was a recent single study done in Europe. The NY Times and Time magazine also carried it. (4)

PARENT: Emma certainly isn’t fat. I remember I breast fed her for close to a year because I wasn’t working at the time. You told me not to start her on solids until after 6 months.

PHYSICIAN: Just a second. Let me look up Emma’s record. …

PHYSICIAN SWIVELS AROUND ON STOOL TO TYPE ON THE LAPTOP.

PHYSICIAN: What’s her birthdate?…our new computerized medical record keeps records only as individual patients, not families. I can’t find Emma’s record.

PARENT She’s eleven now, from my first marriage, her last name is different.

PHYSICIAN: Ah, yes, here she is. …Looks like we were concerned about your family’s history of food allergies, so we cautioned you about not starting foods until she was over 6 months old.

PARENT: Emma is doing great without any allergies. I’d like to start solids on Leonard because he is so fussy at night and seems hungry when he wakes up.

PHYSICIAN: A new recommendation is to start potentially allergic foods earlier rather than later . Small portions of those foods started as early as 2 months of age may actually reduce future allergic reactions. (5)

BEEP…BEEP…BEEP

PARENT: What’s that?

PHYSICIAN SWIVELS AGAIN TO FACE PARENT.

PHYSICIAN: Oh, that’s just my laptop letting me know that this visit is reaching 95% of the usual duration of a well baby visit.

PARENT: So, I should breast feed Leonard for a whole year, but could have started solid foods two months ago? Most of my friends swear that giving food makes their babies sleep longer at night.

PHYSICIAN: Exclusive breast feeding for 6 months has lots of advantages for the infant. There is no evidence that giving solid foods makes the infant sleep longer at night, but there is probably no harm in starting him on cereal now.

PARENT: Any particular kind of cereal?

PHYSICIAN: A 1994 Swedish study showed that introducing wheat before 6 months of age caused a big spike in gluten allergies and celiac disease, but a recent one there showed that giving wheat to breast fed babies at 4 months actually decreased the later occurrence of celiac disease and gluten allergy.

PARENT: So, wheat cereal could be either good or bad at his age? This is very confusing.

PHYSICIAN: Science can be confusing. It often changes its mind as new data is gathered.

PARENT: When I switch to all formula is there any one that is best? Should I start with soy? When I switch to milk, should it be whole milk? … or 2%? … or 1%? What about peanuts?

BAHUGGA!…BAHUGGA!…BAHUGGA!

PARENT: What’s THAT?!

PHYSICIAN: That’s a notice for me that the average duration of a well baby visit has been exceeded by 20%. I really must go on to the next patient. Please go to our practice website where we answer those questions and provide several nutritional advice sites for further information.
Your baby is doing fine.  We’ll see you again in two months.

PHYSICIAN EXITS THE EXAM ROOM AND PARENT STICKS HER HEAD OUT INTO THE HALLWAY TO DIRECT ONE MORE QUESTION TO HER RETREATING BACK.

PARENT: Oh, doctor….do I need a password for the website?

References:
1. American Academy of Pediatrics, AAP.org
2. Journal of Pediatrics, March 30, 2013
3. Fox News March 13, 2013 reporting on JAMA article March 12, 2013
4. NY Times March 14, 2013
5. American Academy of Allergy, Asthma, & Immunology, January 2013

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2 Responses to Vol. 88 April 15, 2013 How Do You Feed a Baby in a Patient-Centered World?

  1. Nice example. The issues are the same for adults. Physicians are always trying to get patients to do something they really would rather not — stop smoking, exercise more and loose weight. Is it a shared decision for a patient to continue to smoke — I hope not. Consumerism (give the patient what they want) and evidence-based medicine are often at odds. In my opinion, poor medical literacy on the part of the patient and poor communication on the part of the physician make consumerism attractive.

  2. Bobby Gladd says:

    That’s funny, man. Would love to cross-post this on my REC blog (w/attribution and links). My readers would love it.

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