IUGR or Pre-term?

This morning one of my prenatal girls proudly brought in her precious little girl for me to meet. She was beaming! When I looked beneath the blankets though, my breath caught in my throat. She was tiny! So small in fact, I had to touch her briefly to make sure she was alive.

“When was your baby born, honey?” She certainly didn’t look like she just gave birth. She was too rested and relaxed.
“Last Sunday.” She said with a smile.
“Oh, you had her yesterday?” I offered.
“No. The Sunday before.” I must have looked confused, so she repeated herself. “You know, a week ago.”

I had to marvel at this little package of estrogen. Could she really be a week old, already?
“She is so small. Why didn’t you come before now?” I asked.
“Oh... we have a tradition in our culture. You cannot take babies out of the home for several days. If it’s a girl you must wait 4 days. But if it’s a boy then you wait only 3 days.”
“I see. Can I do a exam on your baby to see how old she is?”
“Of course you can. I’m here for a check-up anyway.”

I smiled and held back my concern. She certainly didn’t act like she was fighting to live... but she was so small. When I got her on the scale, flash backs of last weeks premature births blasted through my brain. In fact, the second premature baby weighed more than she did! She only weighed 1500 grams (3.3 lbs!).

But as I checked her out... all her vitals were stable and she seemed healthy in every way. So I did a Ballard’s Score on her. This is a test done on newborns to help determine if they are premature and, if so, how much. It tests reflexes, neurological development and physical maturity attributes. It’s only meant to give a general range but it can help differentiate between a small but term baby and a premature newborn.

When I checked her reflexes, postures and muscle tone, she passed with flying colors. Her neurological development was spot on. In fact, I didn’t see anything amiss except her size. At the end of the exam, it was clear to me I was dealing with a severely IUGR baby and not a preterm one.

For those who don’t know, IUGR stands for Intra-uterine Growth Restriction. It means the baby was unable to develop and grow at a normal rate in utero. Something hindered her. It could have been from placental insufficiency or maternal life-style (alcohol, drugs, cigarettes). It is also caused by poor nutrition and illness (chronic or infectious).

I’m not sure what caused hers... but it’s the most severe case I’ve seen to date.

Fortunately, she is fine and eating fairly well. I asked her mom to bring her in regularly so we can monitor her growth. She said she’ll come. I have a feeling she will.

Strange Cases.

It's hard to see but this is the infected breast.

Yesterday a one week old little girl came in with what could only be MASTITIS of the right breast. Her mother reported that she was able to get a lot of milk out of it the day before. When I checked, lots of milky pus was expelled. It was very strange.

I should explain that baby girls sometimes have side effects from their mother’s hormones of pregnancy. These hormones can cause her to have a ‘period’ not long after birth. Some girls have ‘witches milk’ -- or start lactating. It’s normally nothing. The period is only once and the milk goes away after awhile as the hormones make their way out of the baby’s system. But mastitis (aka: infected milk duct)? That’s a new one for me.

My differential diagnosis is a plugged milk ducts, an abscess, breast cancer. But I’m open to ideas and suggestions. My money’s on mastitis though. She’s on meds now. I’ll let you know how it goes.

Hot as death?

Warning: this story might not be for everyone.

Last night, after closing down the clinic for the night, I was ready to head home when three figures walked up with a baby.

I thought about letting the on-call health worker take care of it but God refused to let me go. My feet felt glued to the ground. The figures seem so solemn, so resolved. I decided to assess them and then call the doctor. When I asked them what was wrong, they just showed me the small baby in their arms. He lay calm and still. Too still. He looked like he wasn't breathing.

I figured it was the poor light in front of the clinic so I had them hurry in. I touched the baby and he seemed warm -- hot even. I started thinking malaria. But as I assessed the baby more, it became very clear he wasn't breathing.

I called for my translator and asked them how long he'd been this way. They seemed confused. What do you mean? Isn't he breathing?

As my translator went for the doctors, I started resuscitation efforts. The family was sure that he had just now stopped breathing. "Just as we entered the clinic gate," they assured me. But it didn't look that way. His little hands were curled in tight fists. His body semi-rigid.

I gave oxygen and started chest compressions but was unable to restart his heart. Once Caleb got there we worked on him together. While Caleb did compression, I stopped to take his temperature. He was burning up with a temperature of 38.8 degrees (102 degrees).

Caleb pronounced him dead after assessing the rigidity setting in. Shaking his head to my hopeful looks. When I handed him to his mother, she too shook her head in disbelief. No, he's still warm. He must be alive. She put her ear to his mouth and said there was a rattle. She could hear it. But there wasn't.

It took her several minutes to believe us. She just kept looking hopefully to each of our faces. I told her that her baby was hot not because he was alive but because of the fever that killed him. I told her that we could no longer hear his heart beating. I told her that he wasn't breathing. He wasn't moving. I won't soon forget her face as that news finally settled in.  

I broke down and cried as I prayed for her. She seemed so hopeful. She had come from so far. He was still so warm. And yet all I could offer her was a quiet shake of my head and my prayers. I wanted to give her so much more.

He was only nine days old. He had spend 5 of them on fire. I used to think that death was cold but I don't anymore. I've learned that here, death can be hot as well.

Starving.

I found myself in a strange debate with a first time mom who came to the clinic because her baby ‘refused to suck’.

At first I believed her but then I watched her baby suck on anything it could get near its mouth- hand, blanket, syringe.

She had delivered at home two or three days before and the baby hadn’t eaten once. She was severely dehydrated and slightly jaundiced. More importantly she was lethargic… but still sucking.

Asking a bit more about what happened she complained that her baby just “refused to eat”. Maggie sent her to express milk but she came back saying she could only get out a drop or two.

So they tried to get the baby to take 50% dextrose. She wanted to but most of it came right back up.

Then they tried to get an IV in this wee little one but without success. Her veins were too small.

What to do? What to do?

Then I told the mom I’d like to express milk for her. I noticed she was engorged perhaps it was her technique. When I expressed it for her she screamed in pain, fighting me. All the while repeating how she ‘doesn’t have milk’.

I was able to express easily 100 cc of milk (much more than the baby could take at a time) but the mother still argued with me. She complained that she couldn’t hand express and feed the baby with a syringe because that wasn’t ‘normal’ and she had inverted nipples so the baby had difficulty latching, etc. She said only cow are ‘milked’ is such a manner.

Meanwhile the baby lay too hungry to even cry inches away. All the mother kept doing was complaining about how her baby ‘refused’ to eat.

And all we kept telling her was she had to express her milk (which she refused because it was too painful) and give it to the baby. Or she had to work to get her nipples better so the baby could latch.

We argued incessantly. “Would you prefer your baby die?”, we asked. She never answered. She would only repeat ‘she refuses to eat’. I’d say it’s more like her mother refuses to feed her. In the end we could do nothing more than refer her to the hospital in Wau. 

Lord forgive me but I wanted to steal that baby away from her. Even now I’d love to take that baby and nurse her to health.

I really don’t think she’ll live.