Dispensing empathy in the pediatric setting
“Of course,” I say. “What have you got?”
She clears her throat and begins her presentation. “This is a 2-month-old baby. Mom says she's been fussy for the past week. She doesn't want to eat as much as she had before. Last poop was 4 days ago—she usually poops every 2 days—but mom describes a typical breastfed stool. There's no blood or mucus in the stool that mom could see. She hasn't had any fevers, and she's not been on any medicines. No rashes, head looks normal, the anterior fontanelle is open and flat, no discharge from the eyes or nose. I didn't look in her mouth, because I didn't want to upset her—I thought we could do that together—chest is clear, heart is normal in rate and rhythm with no murmurs, good bowel sounds in the belly, hips are normal, and neurologically, she's bright and alert, very sociable.”
“So what do you think's going on?”
The student's smile fades from her lips. “Hmmm,” she says, “I guess I'm not really sure. The mother's describing a fussy, cranky baby, but she looks fine to me.”
“So your clinical exam is reassuring, correct?” I say.
The student nods her head.
“What's the baby's weight today?”
The student blushes. “Oh, I'm afraid I didn't weigh her today. But she was weighed last week when she was here for her 2-month well-baby checkup.”
“So she probably got her vaccines at that visit.”
The student flips to the immunization record. “Yes, she got her shots and the rotavirus vaccine,” she says.
“Let's go in to see her together.”
We step into the examination room to find a pink cherubic infant nestled in her mother's arms.
“Hello,” I introduce myself. “So I understand you've got a fussbudget on your hands. When did she get cranky?”
“Last week,” the mother says, “right after she got her shots. Do you think that could be why? She's hardly had anything to eat today—usually she downs a bottle of breast milk every couple of hours—but whenever I give her the bottle, she takes a few sucks and then cries. I'm afraid she's getting dehydrated. Maybe she needs to poop—she tries and gets all red in the face, then she cries. Sometimes she passes gas—is that okay? I mean, I just don't know what's the matter with her.”
“Do you have a bottle with you?” I ask. “Let's see if she'll take something now.”
The mother pulls an 8-oz bottle out of her baby bag and inserts the nipple into the infant's mouth. She takes a few vigorous sucks and swallows, then begins to cry. I check the bottle, turn it upside down over the sink, verify that the droplet flow is adequate and hand the bottle back to the mother. I look in the infant's mouth and throat, listen to her chest, and feel her belly.
“Overall, she looks fine,” I say. “This could be a reaction to the oral vaccine that she got last week—sometimes that will upset the bowel—or it could be that she needs to have a stool. At this age, breastfed babies sometimes stool every 2 to 3 days—again, nothing to worry about.”
“What can we do?” the mother asks.
“Let's have you give her a couple of feedings with an oral electrolyte solution to give her tummy a rest. It will keep her hydrated, but the bowel won't have to work so hard to digest it.