Time to Put Infant Reflux Back In Its Box

In all walks of life there are times when you get to enjoy the liberating feeling of being told something you’ve always known to be true, but never quite had the knowledge you needed to confirm your inner convictions. This happens to GPs all the time, because we have convictions and feelings about most of the medicine we encounter on a daily basis, but too little time to research all the myriad quandaries we are left puzzling over. This is where specialists have their use – they are able to dedicate years of study to one or two of the dilemmas we are faced with, and help point us in the right direction.

So it was this week, that one such specialist empowered me with something of a eureka moment over a condition that has been troubling me recently – the increasingly medicalised language surrounding ‘sicky’ babies.

By ‘sicky’ I mean milk-spitting, vomiting, puking babies that leave permanent milky-white stains on the shoulders of all their parents’ best clothes, require investment in dozens of muslin squares and lead to the pulling up of carpets in favour of wipe-clean lino just before the baby miraculously grows out of it. Or to use a lovely, old-fashioned word that we need to keep hold of: possetting.

What I do not mean, is gastro-oesophageal reflux.

Reflux is a highly medicalised word. It is not normal; it implies acid spilling backwards from stomach to oesophagus and (as any pregnant woman knows) painful heartburn. True acid reflux can occur in babies, but it is rare; paediatric gastroenterologists at the conference I attended this week were queuing up to testify as to how unusual it is to have positive tests for acid reflux in possetting babies. This fits with the experience of having a possetting baby (and I have bought my fair share of muslin in my time) – babies are not usually distressed by pain when they posset, and the milk smells just like that – milk, and not acid.

Despite the fact that the entire feed of milk seems to find its way into the washing machine rather than the infant stomach, babies who possett thrive – they put on weight and develop without problem. They are irritable some times, but most babies have times when they are more irritable than their parents would like. If possetting is very common, and irritability is very common, then there will be many babies that experience both, but that doesn’t mean that the possett is the cause of their irritation – or, more  importantly, that treating ‘reflux’ will make any difference to one or either symptom.

Many advice websites give quite a balanced view on this issue, with sites like the BabyCentre and netmums giving lots of reassurance that it is usually normal and will settle on its own before mentioning any medical treatment for it – but they still call it reflux, because the word has entered popular use. Fascinatingly, what I also learned this week is that if parents are told their baby has reflux they are more likely to want medication for it than if the doctor gives the same explanation of the problem, but avoids using the medical label.

Medical labels matter, they create anxiety that your baby has a problem that you should be trying to solve, and can turn a normal, healthy baby into a patient before they have barely got going in life. We need to normalise this process and recapture the word possetting for the nursery and not the doctor’s surgery.

So what of the science behind treatments for ‘reflux’? Well the first thing to say is that true Gastro-Oesophageal Reflux Disease can occur, although it is rare. We need to be concerned about a baby that is failing to thrive (that is, is not growing properly and putting on weight in the normal way), or if the vomit contains blood, or is associated with significant breathing difficulties. These babies may well need to see a paediatrician.

For the vast majority of possetting babies, however, the point in question is this: will any treatments that are offered make any difference to how often my baby is sick, or to how irritable they are? The answer to these two questions is a resounding ‘no.’ Simple measures such as making sure you don’t overfeed, slowing down the feed and winding regularly are all common sense, but changing feed to an expensive ‘stay down’ milk, or low allergy formula strikes me as companies exploiting an artificial niche in the market and evidence of benefit is very limited.

Medications fare no better. Antacids such as Gaviscon are frequently used, as are medicines that stop the stomach making acid in the first place, such as ranitidine and omeprazole (although this is an unlicenced use). When these medicines have been subjected to proper clinical trials they show that they reduce the acidity – but make no difference to how much a baby possetts or how irritable they are.

What is more, there are significant downsides to neutralising the stomach acidity in infants, in the form of increased risk of both gastroenteritis and pneumonia – presumably we evolved to have stomach acid for a reason, and keeping germs at bay may well be part of its role.

So, we have a treatment that doesn’t work, for a condition that doesn’t really exist, and that might make your baby really quite unwell – any takers? Let’s instead try to put reflux back into its box, let healthy babies be healthy babies, and reclaim the word possetting – more of a laundry problem than a medical one!

Hypochondria – a Word Desperately in Need of a Makeover

Hypochondria is an ancient word. It stems from the Greek meaning for the upper abdomen; hypo- is the prefix for below, and -chondro refers to the ribs, so that the Greeks referred imaginatively to the upper abdomen as ‘the bit below the ribs.’ For the Greeks, the abdomen was felt to be the seat of melancholy, in the same way that we consider the heart to be the home of love. At some point in the history of medicine, this psychological association with the word hypochondria developed pre-eminence over its anatomical origins, and the condition of hypochondriasis was born.

Since that time, however, hypochondria has taken a bashing. The problem starts with the fact that it makes such very good comedy. Whether it is an icon portrayal by a master of the art such as Tony Hancock, or throwaway one-liners like ‘Hypochondria is the only illness I don’t have‘, the image of someone endlessly worried about their health is irresistible material for laughs. This I can handle – comedy is part of how we cope with the human condition, and we should never be so sensitive about illness that we are afraid to laugh at it.

More of an issue, however, is when the condition is misunderstood – and unforgivably so, when this is done willfully. A particularly bad example of this was written in The Observer recently by the columnist Barbara Ellen. It may be that she is simply ignorant of the nature of hypochondriasis, in which case she is guilty of gross journalistic laziness, and should improve her research. However, with a sub-title that reads: ‘Hypochondriacs are themselves a pain – and they take up valuable surgery time,’ I suspect that she knew full well what she was doing and was happy to take cheap potshots in order to sell a story.

The text of the article is even worse than the headline. Ellen was apparently trying to be on the side of doctors, empathising with why we might sometimes be tempted to prescribe a placebo. An article that alleges to understand my frustrations as a doctor has rarely left me so angry, but with outrageous claims like: ‘the fact remains that there is no known cure for the determined hypochondriac attention-junkie’ and ‘hypochondriacs are shameless liars’ the only way I was able to keep my blood pressure in check while I re-read her rant, was to remind myself that she is a professional journalist who has set out to shock and I shouldn’t take it too seriously.

There is a serious side to this, however, which is that words affect attitudes, and attitudes drive behaviour. True hypochondria is a fearful and much stigmatised illness; the way we talk about it will influence the way doctors, patients and the public in general behave towards those affected, and at the very least I feel the need to try to redress the balance a little.

At this stage I should say what I mean by hypochondria; it is easier to start with what it is not. It is not someone who worries a bit more than most about their health. Neither does it describe those among us who are – and there is no other way to say this – a bit of a wimp when it comes to suffering. Some of us do complain more than others, and our friends, families, and even our doctors, have to put up with this – but that is not hypochondria. Nor is it malingerers who make things up for personal gain – people who pretend to be ill in order to skive off work for a bit. Despite what the Government would like us to believe, I don’t think there are many people like that, but I would be naive to say that they do not exist – although they are not hypochondriacs. Most importantly, hypochondria does not refer to illness that cannot be explained by doctors – medically unexplained symptoms are common, and their causes many and varied, while hypochondria is rare and quite specific.

A true hypochondriac really is worried that they are unwell. The illness is often focused on one fixed belief – a lump in the throat becomes a cancer, abdominal cramps can only be explained by a bowel infestation. The level of anxiety takes on an obsessional, even delusional, quality, with a constant drive to find an answer for the symptoms, and a need for reassurance that can become like an addiction. Just as an alcoholic finds his thirst is slated only for a while with a drink, so reassurance brings an all too temporary reduction in anxiety, and as soon as it wears off anxiety rises to overwhelming levels, with a search for more reassurance being the only offer of respite.

A patient may check their body for changes 30, 60 or 100 times a day; it can dominate conversation with friends and family, exasperating all involved. The internet – always a mixed bag when it comes to health information – becomes a snare, with its 24-hour availability and tendency to promise answers, while usually delivering just more questions. Reassurance-seeking behaviour, inevitably, involves frequent trips to the doctor, A&E, specialist clinics, investigations – the risk from medical tests and treatments becomes a very real danger. This is a debilitating and life-controlling illness – hardly the domain of a lying, time-wasting whinger.

The challenge with hypochondria is to help someone move from focusing on physical symptoms to an understanding of the nature of their anxiety. This is hard enough without having the very word for their illness mired in stigma, ridicule and misunderstanding. I suspect Hypochondria as a diagnostic label is now beyond rehabilitation – which is why the illness is often referred to today as health anxiety – but the word still exists in our popular vocabulary, and we should treat it with respect, because it will continue to represent the experience of real people with real lives.

On Tesco’s Late Equaliser and the Value of Bite-Sized Chunks

I was delighted to hear from Tesco yesterday in response to my campaign to change the labelling of breakfast cereals in supermarkets. Three letters and a few tweets have finally borne fruit, and Tesco are following Sainsbury’s lead by removing the misleading signs from all their stores. If you have not been following my campaign against the concept of “Children’s Cereals” then you can follow the story in the blog here, here and here. I was even more pleased when I had cause to visit my local Sainsbury’s later that day to find that their signs have indeed disappeared as promised.

Cereals for all – Tesco are removing the sign denoting children’s cereals

It is comforting to know that I will now be able to venture into both stores without having my blood pressure challenged in the cereals section, but this is only a small part of a wider public debate on how we treat our children: If we believe that children will only eat food that is coated in sugar or high in saturated fat, then the chances are that they will grow up wanting to eat food that is coated in sugar or high in saturated fat. It is a debate that we must keep in the public domain, and a war that must be waged on many fronts.

It struck me that there is a parallel with many seemingly insurmountable health problems here, and that this has been a helpful lesson in the immense value of breaking down problems into bite-sized chunks. My overwhelming problem is the challenge society faces with the frightening increase in childhood obesity – surely it is impossible for me to impact this and it seems ridiculous to try. Even if I break it down to the role of the supermarkets and how food is marketed to children I am still defeated into a state of inactivity, believing I cannot succeed. Reduce it further to the issue of two small signs in the cereal aisle and I am starting to think about action – still not confident that I will succeed, but willing to give it a go. And it turns out that it was possible after all. I haven’t changed the world, my problem has not gone away, but I have changed something, and perhaps I can now change something else.

So too with health problems. Maybe I feel crushed by my failure to lose weight, cannot consider how to face the week without the comfort of a bottle of wine or am overwhelmed by anxiety every time I consider venturing from my home. The scale of my problem is so great that my spirit is broken from the start, and I tolerate the status quo for months, even years, because I cannot even imagine any other way. The way forward has to be to imagine a different future, look at the problem in a new light and find a bite-sized chunk that I know I can break off, where I have some confidence that in a small way I can succeed.

So with weight loss – to set the challenge of losing a certain amount of weight in a set time often sets us up to failure – but perhaps it is not so unrealistic to aim to make one small change: maybe the biscuit with your coffee becomes an apple, maybe three potatoes becomes two, or the lift is exchanged for the stairs. The lover of wine might not be able to contemplate cutting down to recommended limits just yet, but perhaps they can consider having one day a week that is alcohol free; and the person with anxiety may not be ready to book a holiday to Venice, but could they find a friend to help them and venture somewhere new just a little outside their comfort zone?

When we break things down it is vital that we are careful how we measure our success. If I were to measure my campaign against the level of childhood obesity in the UK I would clearly see no impact at all and might berate myself for trying. In the same way, if you challenge yourself to change a biscuit to an apple, assess your success on just that – have you kept your promise to yourself and are you eating fewer biscuits? It is unfair to measure your success only in terms of the bathroom scales – that will come in time, but we need minor victories along the way to win the war. Success is empowering, and we need to practise it if we are to overcome the more intransigent problems, both in our own health and in society.

Fear According to Pi

From time to time, you come across a piece of writing that is so compelling, so beautifully written, so resonant with what matters to you that you want to shout it from the rooftops – to call to anyone who will listen and declare to the heavens: “Look at this everyone! Stop whatever you are doing! Just stop for a moment and read this!”

So with Yann Martel’s marvellous novel Life of Pi, and more specifically chapter 56 – a single page offering that is the most powerful, emotive and yet eerily accurate description of fear that I have ever come across. It is worth quoting here in its entirety. If you have ever experienced the overwhelming power of panic, you will relate to every word and find relief that someone can so reliably describe how you felt. If you have never been to the depths of fear, it is worth reading all the more so that you can  understand better those that have.

I must say a word about  fear. It is life’s only true opponent. Only fear can defeat life. It is a clever, treacherous adversary, how well I know. It has no decency, respects no law or convention, shows no mercy. It goes for your weakest spot, which it finds with unerring ease. It begins in your mind, always. One moment you are feeling calm, self-possessed, happy. Then fear, disguised in the garb of mild-mannered doubt, slips into your mind like a spy. Doubt meets disbelief and disbelief tries to push it out. But disbelief is a poorly armed foot soldier. Doubt does away with it with little trouble. You become anxious. Reason comes to do battle for you. You are reassured. Reason is fully equipped with the latest weapons technology. But, to your amazement, despite superior tactics and a number of undeniable victories, reason is laid low. You feel yourself weakening, wavering. Your anxiety becomes dread.

Fear next turns fully to your body, which is already aware that something terribly wrong is going on. Already your lungs have flown away like a bird and your guts have slithered away like a snake. Now your tongue drops dead like an opossum, while your jaw begins to gallop on the spot. Your ears go deaf. Your muscles begin to shiver as if they had malaria and your knees to shake as though they were dancing. Your heart strains too hard, while your sphincter relaxes too much. And so with the rest of your body. Every part of you, in the manner most suited, falls apart. Only your eyes work well. They always pay proper attention to fear.

Quickly you make rash decisions. You dismiss your last allies: hope and trust. There, you’ve defeated yourself. Fear, which is but an impression, has triumphed over you.

The matter is difficult to put into words. For fear, real fear, such as shakes you to your foundation, such as you feel when you are brought face to face with your mortal end, nestles in your memory like a gangrene: it seeks to rot everything, even the words with which to speak of it. So you must fight hard to express it. You must fight hard to shine the light of words upon it. Because if you don’t, if your fear becomes a wordless darkness that you avoid, perhaps even manage to forget, you open yourself to further attacks of fear because you never fought the opponent who defeated you.

This ‘wordless darkness that you avoid’ is the hallmark of fear. The key question to ask if you suffer from anxiety is this: Do you avoid anything that most people see as routine? Avoiding activities such as bungee-jumping is most people’s idea of common sense, but what about using a lift, getting on a train, going into a room with a spider in it, or having an MRI scan? The military analogy works well here; fear is like an invading army that can annex part of your life if it is left undefeated. The greater the fear, the more restrictive the occupation can become, and negative phrases like ‘I can’t’ and ‘I don’t’ become commonplace. Avoidance behaviour seems so natural and logical that it often creeps in unnoticed and unchallenged over years.

It is possible to reverse this trend, to reclaim the occupied land and plan a strategic advance into enemy territory. It is not easy, as it involves facing up to fear and staring it down until eventually, like any bully, it reveals itself to have less substance than first seemed (it is, after all, ‘but an impression’). Each victory over fear, no matter how small, diminishes its power – making the next step in the campaign seem possible, and ultimate victory a realistic goal.