Baby Priscilla Follow-Up

Do you remember Baby Priscilla? No? Well, that's because I only thought I wrote a blog post about her. Now that I look back, I don't see it. I intended to. I often have a story or two in reserve for that day that I find myself blogless.

Priscilla was admitted at age 1 day with respiratory distress and poor breastfeeding. We had to treat her as as having neonatal sepsis, with 10 full days of intravenous antibiotics. Baby chest x-rays are often hard to interpret. For wone thing, the little twerps just won't cooperate with proper positioning, taking and holding a deep breath just when the picture is exposed. So sometimes the heart can look a little large, even in a normal kid. Priscilla heart looked just a bit on the large side. There was just a little bit of increased lung density in a place or two. Pneumonia? Congestive heart failure? Your guess is almost as good as mine.

The problem was that her oxygen saturation (that's come up a few times lately) didn't improve with antibiotic treatment. After a few days of hand feeding with a dropper, she started breastfeeding. I kept listening for a murmur that would suggest that she had a structural heard defect, but the noisy peds ward isn't exactly the best place to hear a soft one.

After repeating the chest x-ray a couple of times I convinced myself that the heart was in reality a bit bigger than it should be. Finally I knew that I'd have to bite the proverbial bullet and treat her with medicines for heart failure. The tiny doses required by such a small baby present a challenge. I had them use the injectible form of one of these meds, and dilute it in a bottle of infant vitamins, and calculated a volume that was large enough to be easy to measure, small enough for a little baby to take easily.

After a few days, I had started to think that this was a mistake, and wasn't doing anything. Each morning I'd check her saturation. It would be great with supplemental oxygen, but fall rapidly if we turned the oxygen off. Then after about a week, and a little adjustment of her meds I started noticing that the saturation wasn't falling as fast, or as low. One morning about 2 weeks after starting the heart meds, it stayed in the 90s. My student nurse went back and checked later in the day and reported that it was still good.

I watched her for another couple of days. Just before discharge, in an unusually quiet moment on the ward, I heard the murmur, tending to confirm my suspicions of a structural heart defect causing heart failure. I discharged her, initially with a follow-up in about 3 days, and then after another 10 days. That was this past week.

The first thing that I noticed was her impressive growth! She was huge! And obviously well-nourished. Her saturation was 94%, and her chest x-ray actually looked a little better than the last one in the hospital. The heart size was actually slightly smaller, despite the impressive growth of the rest of her. The murmur was still very soft, but I could hear it clearly in the relative quiet of an OPD exam room.

I went over the facts of the case again with her parents. We don't know what the exact cause of her heart failure is. We may be able to find out next May, when they will do screening for the Australian heart surgery team that come annually to PNG. The problem could be something that will become less significant as she grows, and she could end up being essentially a normal kid. Or it could turn out to be a life-altering, life-shortening serious problem. For now, as long as the meds are working, we'll stick with them. They promised to come back faithfully. I prescribed a month's supply of meds, and sent them on their way.

Sometimes, even with limited resources, limited diagnostic abilities, limited skill, we get to see good outcomes. Thanks, Lord.


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The first photo is of Priscilla and her mom and dad the day they left the hospital. On the parents' faces it's easy to see the anxiety of leaving the hospital for the first time since their daughter's first day of life, hoping that the home-made concoction of medicines made up by some wild-eye'd American doctor would keep her alive.

The second photo is from this past week. They look a little more confident, don't they?