I haven’t had the bandwidth to blog or even write for myself in a long time, between my clinical responsibilities and time focused on my research and other projects. But inspiration comes sometimes, so I finally put pen to paper (fingers to keyboard?) a few weeks ago and drafted an essay. Ultimately, I decided to be brave and share my own writing (full drafted and edited, as opposed to just impromptu) on this medium for the first time. I hope it inspires you to write down your own thoughts as well.
Black, White, and Gray
It seems like every pediatrician has one: a story about co-sleeping that ends in a dead infant. Usually, they present the same way. The parents put them down for a nap and curled up beside them. When they woke up, the baby wasn’t breathing and had no heartbeat. They were rushed to the emergency department and could not be saved.
It’s horrible for the family, and there is no doubt that their loss is the most profound.
But it is also a story that we, as the pediatricians, never forget.
I am trained as a physician scientist. During my PhD training, I learned how to critically interpret data, evaluate study design, and understand the nuance that accompanies the results of every experiment. And I empowered myself and others to conduct experiments on our own, armed with the knowledge that the truth and best practices were always changing and that the world was full of gray areas.
Much of that subtlety was thrown out of the window as I entered my clinical training. Yes, medicine is based in clinical research that is conducted in that same way. But medical school teaches you to memorize tidy little snippets for tests and choose the best multiple-choice response to a clinical vignette. We are trained in pattern recognition, standards of care, and practice guidelines. We have to apply these rules during 10-minute visits where there is no opportunity for critical reflection for the parent, the child, or the practitioner. There is some room for creativity (“the art of medicine”), such as when existing clinical evidence is not clear cut, as is often the case in pediatrics. However, there are many situations that we treat as completely black and white.
Safe sleep. Vaccines. Vitamin K at birth.
And to a lesser extent: Breastfeeding. Screen time. Healthy diet and exercise.
Halfway through my residency training, I have softened on a few of these positions. Due to the COVID-19 pandemic, I have learned to embrace my patients’ and their parents’ humanity when it comes to screen time and healthy eating. If there are days (weeks?) when I have a donut and a cup of tea for breakfast, who am I to judge them for their choices? I can educate them and offer them the medical recommendations, while still acknowledging their reality of working a full-time job and simultaneously educating and caring for their children with little control over their daily habits. My job is to share my expertise and use it to help them meet their goals as a family.
I have even become more flexible with vaccines and postnatal vitamin K. I am sure this would be different if I had seen an unvaccinated child present with preventable life-threatening epiglottitis or meningitis or a severe intracranial bleed. However, thanks to wide-reaching immunization campaigns, in my young career so far (we will see if this changes), those scenarios have been relegated to board question stems and the writings of William Carlos Williams. I am also more aware of many of the reasons for hesitancy surrounding vaccines and medications for infants among various populations. So I provide my parents with my recommendations and literature to support my claims, and I let them make their own informed decision, making sure they are well aware of the risks. Ultimately, even if they do not choose to vaccinate, they still trust me and count on me when they have other questions and concerns about their child’s health. I would rather them not vaccinate and continue to bring their child to see me than to lose contact with them entirely.
But co-sleeping? This situation evokes a visceral response. My first thought is always, “Do you want to suffocate your baby? Do you know how many babies have come in dead from co-sleeping?” Admittedly, this is not the most helpful approach, so the thought resonates inside my mind until I gather my composure enough to have a conversation with the parent about risk-mitigation.
Since the Back to Sleep campaign started in the early 1990s, sleep-related deaths (including those from suffocation and unknown causes) have stabilized at between 80-100 per 100,000 live births. That’s 0.1% of otherwise (as far as we know) healthy children, or about 3500 deaths per year1. As a pediatrician and a human being, that seems like a lot of babies to lose. But that data doesn’t tell the whole story. Not all of those deaths would be preventable if the baby were alone, on their back, in a crib. More granular data indicates that about 24% of those deaths are due to suffocation or about 800 deaths per year2.
When you have witnessed a family experience that loss, it is hard not to fight tooth and nail to prevent as many of those deaths as possible. But I am not a parent. I am not up every two hours breastfeeding. I have counseled patients on strategies to console a child with colic, but I have never been the one to drive an infant around the block for hours until they have cried themselves to sleep. And as much as I say that I will stay strong when I make my future child “cry it out,” I am not 100% sure that that is actually true.
And so I gather my data. I pull my empathy out from behind the trauma-induced wall of fear I have constructed, and I talk to the parents about mitigating risk. If they insist on co-sleeping, I have to give them my medical recommendations, make sure they are informed, and do my best to help them create a safer sleep environment in their bed for their child. That is all I can do.
And if that baby is the next one that comes in in cardiopulmonary arrest? I don’t know if I could handle that. But I guess I’ll have to.
The prompt for this week is this:
“Write about gray areas.”
You have as much or as little time as you would like. See you next week.
References:
- Mathews TJ, MacDorman MF, Thorna ME. Infant Mortality Statistics From the 2013 Period Linked Birth/Infant Death Data Set. Natl Vital Stat Rep. 2015;64(9):1-30.
- Sudden Unexpected Infant Death and Sudden Infant Death Syndrome. Centers for Disease Control and Prevention website. Updated 20 November 2020. Accessed 18 Febuary 2021. https://www.cdc.gov/sids/data.htm
Writing for Wellness 