Think Like a Doctor: The Baby Who Won’t Eat

April 5, 2013

The Challenge: Can you solve the mystery of a baby who refuses to eat?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to take on a difficult case and offer their own solution to a diagnostic riddle. This week, you’ll find a summary of a 3-month-old baby who suddenly won’t eat. After a day and a half, the parents took the baby to the hospital, where doctors and nurses worked around the clock trying to figure out what was wrong.

Can you figure out why this baby can’t eat? I will provide you with the data that was available to the doctors who made the diagnosis.

The first reader to offer the correct diagnosis gets a signed copy of my book, “Every Patient Tells a Story,” and the satisfaction of solving a difficult case.

A Mother’s Terror:

The middle-aged mother watched her tiny daughter lying quietly in the hospital crib. It had been a terrible couple of days. Suddenly the 3-month-old baby’s plump pink cheeks lost all their color. An alarm sounded, and seconds later a nurse hurried into the room.

The nurse glanced at the oxygen monitor, then quickly placed her baby-sized stethoscope on the infant’s chest. She grabbed the clear plastic suctioning tube and eased it through the baby’s lips, deep into her throat. Clear saliva bubbled up the tubing, making the incongruent slurping sound of the last drops of a drink through a soda straw.

Another nurse appeared with a small, clear face mask, out of which hissed moist steam. She held it in front of the baby’s nose and mouth.

The baby cried with the mews of a small kitten. Slowly, the numbers on the oxygen monitor changed direction, clicking from the 80s up into the 90s as color crept back into the baby’s face.

The pediatrician watched the flurry of activity with concern. The mother looked expectantly at this wonderful doctor who had spent so much time with them caring for their child. She saw a flash of what looked like fear cross the pediatrician’s face. A pang of terror knifed through her; she reached for her husband’s hand. Maybe they weren’t going to be able to figure out what was wrong with her baby after all.

The Patient’s Story:

It had started a few days earlier when the baby, rosy and fat, turned away as she was nursing. She hadn’t eaten as much as she usually did, but this was the mother’s second child and she knew that a baby’s appetite could wax and wane from day to day. When the child only ate once the next day, she started to worry. And when the baby turned away from the breast again the following morning, she called her pediatrician.

The doctor was worried, too, and after examining the baby, sent the two to an ear, nose and throat specialist to look for an object that might have gotten caught in the baby’s breathing or swallowing tube. When the subspecialist found nothing, the pediatrician sent mother and daughter to the local hospital for I.V. fluids and further evaluation.

The pediatrician at the hospital thought the child probably had picked up some kind of virus. She had no fever, and her vital signs and exam were normal except that she was irritable and maybe seemed a little weak. She was given fluid through an I.V., and blood and urine samples were sent to the lab for testing.

Those tests were normal, as was a chest X-ray and a CT scan of her abdomen and pelvis. A spinal tap was performed and was unremarkable. Despite the normal test results, the team started the infant on antibiotics, just in case she had an infection.

The following day, the baby was no better. She was still not eating and seemed to be getting weaker. That night her oxygen level dropped and only came back after her secretions were suctioned out and she got a breathing treatment. The next day, the parents and doctor decided to transfer the baby to a hospital with a pediatric intensive care unit. They weren’t sure what the child had, but it was obvious she was getting worse.

Moving Hospitals:

At the end of the baby’s second day in the hospital, she was transferred to the Morgan Stanley Children’s Hospital in upper Manhattan. Dr. Pelton Phinizy, a pediatric resident in his last year of training, was on call. He had heard about the transferring baby late that evening. And when he saw the ambulance crew wheeling a baby onto his ward, he fell in behind.

He quickly reviewed the note and labs sent from the community hospital. She’d had an extensive work-up for any infectious cause of her symptoms which, he noted, hadn’t revealed much. Then he went in to meet the parents and see the child.

“As soon as I saw her, I knew there was something wrong,” the third year resident told me. “All my alarms were going off.” The baby lay splayed on the bed like a starfish. Her eyelids seemed droopy, like she was about to fall asleep. And there was a quiet gurgle emanating from the back of her throat.

A New Doctor:

Dr. Phinizy introduced himself to the parents. They told him that the baby had had a normal birth and, until two days earlier, had been well. She had been breast-fed, with occasional formula, until she started to refuse to eat. She had stopped making urine while she was at home after a couple of days of not eating much, but started again when the I.V. fluids were given at the community hospital. She had not had a bowel movement for five days.

There had been no trauma and no known exposures to any illnesses. She and her sister, who was almost 2, went to the local park most days, but the older child was fine, with no symptoms at all.

The baby had received her 2-month vaccines on time. She had no allergies. And there was no family history of any inherited illnesses of the muscles or nerves. Since getting sick, she’d had no fever but, the parents thought, she sounded a little congested. And she’d been a lot crankier than usual, as if she weren’t feeling well.

Examining the Baby:

Once Dr. Phinizy had asked all his questions, he turned back to examine the baby. She was plump, and her cheeks were pink. Her eyes, though only half open, were alert and moved normally, and she was breathing easily.

When the doctor picked her up, however, her head flopped back as if she were a newborn. By this age, most babies can hold their head up at least briefly. Her arms and legs hung straight down, and she made no effort to move them.

He lay her back onto the bed. Picking up one arm, he pulled it across her chest to the other shoulder. Normally, the hand should get to the shoulder but, because of the shoulder muscles, should not move beyond. This baby’s hand moved well beyond the shoulder, and her whole arm lay strangely flat, like a scarf pulled across her upper chest.

The doctor pinched her toe and felt her try to pull away, but very weakly. A normal baby would have a vigorous response to that kind of pain. He put his pinky in her mouth and she tried to suck on it, but wasn’t able to. When he touched the back of her throat with a tongue depressor, she did gag, but the rest of her reflexes, in her arms and legs, were completely absent.

Reviewing the Records:

Once Dr. Phinizy had completed the exam, he went back to the records sent from the community hospital. She’d tested negative for both the flu and a common respiratory infection known as R.S.V. They had worried that her intestine might have been injured and had gotten an ultrasound and CT scan, but both were normal. They’d removed some spinal fluid to see if the baby had some type of meningitis. Those results had been normal as well.

Blood and urine had been sent for culture, to see if any bacteria grew from it, but those results weren’t back yet. Meanwhile, the baby continued on I.V. antibiotics, in case this was an infection.

Dr. Phinizy gathered his thoughts before picking up the phone to call the attending physician who would be caring for this baby. What could be keeping this baby from eating?

Solving the Mystery:

That’s the question I now pose to you: What is wrong with this child?

I have summarized the information available to the doctor who made the diagnosis. What are your thoughts? If you want more specific results, ask and I’ll provide them. And we’ll give you the solution to this puzzle on Friday.

Rules and Regulations: Post your questions and diagnosis in the comments section. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

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