Monday, October 22, 2012

Formula Facts Versus Fiction - Part 1

As you know, JaneMD loves Part 1 and 2's. So here comes another one on formula . . . particularly since some people have expressed some interest in more about newborn care/prices

Real conversation in the outpatient office:

Patient's Mom: My baby spit up alot since I changed to step 1 formula at 2 months. So we tried the sensitive formula; she was still gassy. I tried soy for a few weeks and she seemed better, but after she had a big spit up, I went out and bought some Alimentum now that she's five months.  She doesn't like it very much, but she's stopped spitting up. I know she's lactose intolerant.
Me: How many ounces were you feeding her at a time when she was 2 months old?
Patient's Mom: Eight
Me: How many ounces does she take now at a time?
Patient's Mom: Six or seven

This mom has fallen into a trap that I think of as 'The Great Formula Lie.' This mom had no idea she was taken in by advertising and false claims. She spent alot of money and time switching formulas for spitting up when if she had not overfed her two month old, took some precautions like sitting her baby upright after feeding, or asked her doctor, she very likely would have it avoided completely. 

So in this two parter, I will discuss major lies - I mean 'selling points' that marketing trying to use on you.

#1 - Stepwise formula:
Ah, Enfamil. Even though I was a solid breastfeeding mother for the first 7 months of life, you continued to send me formula samples. Your advertisements said things like 'I am not a baby, I am an infant.' All ridiculous lies. I appreciate that you sent me a sample of Newborn and Step 1 once a month, though because it was free.

I once set those Newborn and Step 1 cans next to each other and examined the ingrediates and nutrients. Essentially exactly identical. The ONLY difference was Newborn had 75 units of Vitamin D and Step 1 had 60 units per 5 ounces. That is all. The entire difference. Both claimed to have prebiotics, both claimed to have DHA and ARA. 

Well, Vitamin D must make a difference, right? Not really. Your child is recommended after the age of 3 months, if breastfeeding, to get 400 IU of Vitamin D daily. Step 1 formula would require drinking of 33 ounces and Newborn formula would require 27 ounces a day. The newborn formula claims to be used 0-3 months, and the step 1 is 0-12 months. Except you don't need vitamin D supplement until 3 months of age and then you don't really need the newborn formula, or you could buy all newborn formula since the difference is so small.

I grabbed Walmart formula and guess what - it is completely identical to Step 1 Enfamil! Everything is the same - including its claims for DHA, ARA, and prebiotics. This is because the US FDA controls what is in formula and it must meet a certain requirement so all formulas, Enfamil, Similac, any generic are nutritionally, for all intents and purposes, the SAME. In fact, there are no studies that show outcome (IQ, growth, and so forth) over any type of formula in a normal child. These claims are like stating that using a 'Graco' carseat over a 'Costco' carseat will make your child more likely to graduate college.

Enfamil also started sending us 'Enfagrow' stage 2 powder for kids older than 1 year old. However, there is no reason to be giving formula to a normal child after he/she turns 1. The label claims to be much better than whole milk - though hilariously the first ingredient is whole milk. If you are still feeding your child formula at a year, you are failing introducting new foods.  Your child should be taking up to 24 ounces of milk a day and all the rest of his/her nutrition should be from FOOD. Not formula! For much cheaper, feel free to feed your child whole milk and give them a chewable vitamin with iron once a day. Many kids can be picky eaters, and this is just to bolster any nutritient they may be missing.

#2 - Marketing through fear:
The label on the advertisement for Enfagrow reads "Enfagrow Preminum Toddler or Milk? **You decide**" (It really said that.)
Translation: You are failing your child if you do not buy this formula. Even better, they have a random well groomed woman in a white coat holding her glasses. I assume, since she is unlabeled, not wearing an ID, and testifying her love of Enfamil, she is a model portraying your friendly pediatrician. (Similac is has similar ads; I just happen have the advertisement on hand)

Look at the claims on a typical can of formula. You'll see they claim improved brain growth, size increase, and all sorts of other things. As I said, since formula is controlled through the FDA, all of the differences between the standard formulas are going to be minimal. You can't fail on any of them. We did all Walmart formula for the first child and are currently using Enfamil because I get it free as a hospital employee.

Don't be confused - there is nothing wrong with using formula. Not everyone wants or needs to breastfeed and that is OK. Just don't fall for the marketing that tries to convince you one is better than the other.

To be continued in Part 2 next week where I'll discuss various types of formula that are out there.

Saturday, October 6, 2012

Glorious resident lifestyle continued

It took a little longer than planned to get my post up because of the Jewish Holidays. The High Holidays were upon us and had all sorts of no computer rules. In order - Rosh Hashana: repent, eat big meals, Yom Kippor: repent, don't eat at all, and Sukkot: celebrate by eating all meals in a hut with no roof for a week - hence today's photo of 'hospital sukkah'.

Returning to the actual planned content of my post: In Glorious Resident Lifestyle part 1, I established that I worked hard and was paid badly as a resident. So what exactly did I do during my 30 hours of call?

My typical call day as a 1st year pediatric resident:
6am: arrive and get sign out about events that happened on my patients overnight.
6:30-8am: examine and talk to each patient. Update patient record (daily notes) on 3-10 patients depending on census
8am-9a: attend educational conference if possible, continue to write patient notes.
9a-12noon: round on all patients with whole team - 12 to 30 patients. Leave group to perform procedures - deliveries/lumbar punctures/cpr/central lines
12noon-1pm: educational lecture. take sign-out from person who was just awake 30 hours.
1pm - 5pm: complete patient work, perform procedures, admit new patients, sign out all other team members
5pm-6am: continue patient work for 12-30+ patients, perform procedures, admit new patients, 10pm nursing/patient check. Possibly sleep in call room if kids stable. Possibly sleep at desk outside of unstable kids room. Possibly sleep not at all.
6am: sign out other patients to rest of team.
6:30am-8am: see all patients, write all notes
8am: educational lecture, try to stay awake
9am-noon: round on patients again, try to finish all work to sign out by noon at 30 hour limit.
noon - 6pm: sleep
6pm: HubbyLawStudent arrives home. Based on business of call night and cleanliness of apartment,  may or may not have an arguement.
9-10pm: go to bed because it starts again at 6am

Staying awake for 30 hours was the worst and hardest part. I was usually pretty good until about hour 20-22, and then my productivity died horribly. Sure, I had a call room that I could possibly have slept, in theory. Winter is the worst because of RSV season leads to a huge number of hypoxic - not getting enough oxygen - infants. July is hard because the new interns need alot of attention and guidance. June is probably the least busy pediatric month, everyone has the most experience and kids are out of school avoiding germs.

That was as an intern. As a senior resident, you got to do 12 hour shifts instead of calls - except you would be scheduled for 13 shifts in a row with 12 hours off in between each one. With the new 60 hour work week, that averages out to 5 x 12 hour shifts per week. Nurses, btw, work 15 x 12 hour shifts over a full month which is like 3.5 per week. They would also get paid overtime or night-shift differential, which residents do not.

If you thought that sounded rough, imagine being a surgical resident. They have schedules like that for 5 or 6 years. You can pretty much cut out my lunch or rounding time and replace it with 'surgery' for hours on end. OB? Replace lunch or lecture with 'wait for babies to be born/c-sections' which they do for 4 years. Pediatrics, family medicine, ER, and internal medicine (among others) are considered pampered lightweights.

 This says nothing about what it was like emotionally to be a resident. You were exhausted, you were in charge of training the other interns and medical students. You had to achieve a certain number of procedures to graduate and pass various national exams. You had to deal with blood, puke, pee, poop, and pus. You were sometimes belittled or yelled at by attendings, nurses, other residents, fellows, and parents. Whole blogs are dedicated to how alone and powerless you often felt. It's not a suprise that arguing with my spouse got mentioned as part of my post call ritual.

As an attending hospitalist, I have a WAY better schedule. I work around 50 hours a week, with some call at a lower risk facility. I also get paid twice as much as a resident, which is still considered pretty low, even for a lower paid specialty like pediatrics. I could have added 20K to my starting salary if I had joined a group practice or wanted to work more.

(I'm lucky because pediatric subspecialists are generally overworked and understaffed because they take 3 more years to educate after residency. There are whole metropolitan areas where there is ONE pediatric geneticist for 2 million people. That means they are on call 365.25 days/year, can't take vacations because if a kid with adrenoleukodystrophy gets a stomach virus, they have to be available to manage the correct fluids and treatment.)

If you want a TV representation of what residency is like, I would recommend Scrubs as your look into our lives.

To end on a funny Scrubs-esque note, here are 10 Things that I actually heard during Sign-out.
Be warned - partially funny and partially cynical. Remember, these are from people who were awake for 30 hours.

1. That asthmatic patient, did you forget to tell me he was missing two limbs?
2. To the Jewish doctor - This Orthodox Jewish family has all these weird rules on Saturdays. Do I need a social work consult? (No)
3. We'll just say this family is pretty 'concrete.'
4. This patient weighs about three Kentucky Fried Units.  (450 pounds)
5. Her/his mom handed me a book on the vegan/gluten/dairy/sugar/preservative-free/all natural/organic diet she uses on her child.  We're treating him/her for malnutrition.
6. We had a Soap opera baby today. The woman didn't actually have a child but have been lying about it for three years and now theoretical father wanted to see imaginary child.
7. I could tell you all twenty meds the specialist put them on, but they haven't taken any for three years.
8. Child is fine; mom left to go use cocaine. CPS is waiting for her when she gets back.
9. This child was stabbed in the vagina by a rhino. Not a real rhino, a rhino statue at the museum.
10. Don't open the security bed, even if the delusional psychotic teenager seems better. He just beat the cr@p out of his mom, and it took 4 security guards to tackle him on his last escape attempt.