My day at the office was pretty routine at 8:30 am with sick visits but soon enough the schedule filled up with pre-holiday sick visits. Understandably, parents wanted to ensure that their children did not enter the three day Holiday with an ear infection or strep throat and thus it was a pretty busy Wednesday morning. Especially this year, I noticed that many of our patients received the change of schedule notification email and hurried in with their children.
After seeing most of the patients I sat down at my desk and called a few concerned parents. One of my last calls was to a new mother that I must have spoken to a half dozen times since her baby was born a few weeks earlier. She was initially concerned about the baby being yellow and had some questions about nursing and now, before Rosh Hashanah, she reported that the baby spit up his bottles more often and seemed more fussy than usual. This change was noted since Tuesday evening. It was interesting that he was a pretty happy baby before that and he did not have any fever or any signs of a bad cold. Initially, I suggested to try a more gentle formula and asked the mom to keep in touch.
As I entered my house at about 3 pm, I was greeted with a very enthusiastic group of kids. It was a true pleasure seeing my children all work as a team to prepare for Yom Tov. As always, I took the opportunity to take some pictures and document these memorable moments. Its not every day that one of my boys wears an apron and helps bake while another is busy peeling pomegranates, and its especially special to see my 1st grader peeling apples.
I decided to jump in and help with some cooking and setting up, and at about 4 pm I headed towards my parents house to see if they were in any need of help. I noticed that the last caller paged me again, reporting that the new formula was not agreeing with the baby, and figured that it would be best to speak with her on my way to my parents house, so that the music and noise in the house would not distract me. after calling a few times I was able to reach the mom. I asked a few more questions this time, like how many dirty diapers he made in the past 24 hours. is he keeping anything down? Did I hear you say that he forcefully spit up? Exactly how many weeks old is he?
Here was the whole picture. By 4 pm, he spit up for almost 24 hrs and was uncharacteristically fussy. He did not pass any bowel movements for almost a whole day and that was also a change for him. His vomiting was reported to be forceful and persistent. Lastly, he was exactly 3 weeks old.
Having this information, I took some more time to go through the possibilities with the mom.
First, common causes of vomiting - viral illnesses - our office was filled with babies with colds and diarrhea and or vomiting - these babies need a little bowel rest from the lactose rich formula and some hydration with pedialyte, and they bounce back very nicely.
Gastro-Esophageal Reflux - these babies usually spit up and/or are very fussy during and after the feedings. Reflux usually develops slowly and parents usually notice a gradual aversion to feeding and more frequent arching of the back.
Next, Milk Allergies - babies often have milk allergies and can start spitting up more often, become fussy, and have bloody bowel movements if the formula is not changed to a hypo-allegenic one.
Lastly and most importantly, there is a rare condition called Infantile Hypertrophic Pyloric Stenosis (aka - Pyloric Stenosis) which can cause persistent, forceful and often projectile vomiting in infants. This condition is more common in first born males and it usually manifests itself between 2-6 weeks. This is one of the diseases that Google will commonly suggest if you search for the words “projectile vomiting”. Even though hundreds of parents are convinced by Google that their beloved infants suffer from this 2illness, I have encountered this condition only once before in my 13 year career as an attending pediatrician, and I vividly remember that it was quite challenging to convince the mom that her young, delicate baby needed an emergency surgery.
About 9 years ago, I saw a baby in my office in Kiryas Yoel who was persistently vomiting for a few days. He had all the signs of pyloric stenosis - projectile vomiting, 3 weeks old and no bowel movements for at least 2-3 days. The case was very straight forward in my eyes. However, in my attempt to help that baby, I remember calling the Bubbie in Canada and explaining why waiting a few more days would put the baby’s life in danger. That baby had a special angel watching him, and his name was Rafael - the Hebrew name of the healing angel. Although he persistently vomited for 3 or 4 days, his mom made it on time to the Emergency Room - the Bubbie from Canada had enough leverage to save the day.
Being that we were 3 hrs away from the start of Rosh Hashanah and the diagnosis was uncertain, I gave the mom clear instructions. We would attempt to hydrate the baby with Pedialyte (an electrolyte drink for infants) and slowly increase the amount. If the baby continues to vomit, he likely has Pyloric Stenosis. If that happens - I suggested to head over to the Cohen’s Children’s Hospital at LIJ where he would have an abdominal ultrasound to confirm the diagnosis.
This time, there was no resistance from the mother, she agreed with the plan and headed over to buy Pedialyte. I noticed that a few minutes later the mom paged me and asked if I could call the Bubbie to go over the plan. Of course I thought, we must make sure that we have the Bubbie on our side. I had a pleasant conversation and went over the different possibilities with her. I actually think we were able to refine the plan a little and I was happy that there was complete support from her.
On a few occasions during Rosh Hashanah I prayed for the baby. Ultimately, my wish was that he would return to himself, I was hoping that he had a minor, self limited viral illness but hoped that if he did require surgery, he would have a quick recovery.
On Saturday night, I restarted my phone and saw that I had received a message from Cohen’s Children’s Hospital ER. It was one of the pediatric residents calling to inform me that the baby underwent surgery for Pyloric Stenosis successfully. I immediately called the mom to ask how he was doing but could not get through. I spent 20 minutes on the phone trying to locate the baby’s room in the hospital to no avail. During this time, apparently his mom was trying to reach me as well.
I was so excited to hear that the baby was doing great. He arrived to the E.R. a little after midnight on the first day of Rosh Hashanah and had the ultrasound done. After the confirmation, the parents were told that typically, babies with pyloric stenosis need IV hydration to correct the loss of fluids and acid deficit due to the persistent vomiting. The surgeon they said, would only come in after the baby is hydrated, so they all anticipated to spend the night waiting. But to everyone’s shock this baby’s blood tests came back absolutely normal!!! There was no sign of dehydration or acid deficit. (in retrospect, the mom thinks that the quick diagnosis of the stenosis, coupled with giving the baby pedialyte slowly must have provided the baby with enough fluids to keep him from dehydration)
The E.R. called the Pediatric Surgeon on call - Dr. Andrew Hong was on call that night (I happen to have seen him during my residency in Cohen’s 2000-2003) and at approximately 2 am he started the laparoscopic procedure. At Cohen’s it is not unusual to see surgeons get out of their beds in the middle of the night to help a baby get the care that he needs a little faster. I recall at least 2 other cases when I was a resident and asked the pediatric surgical team to operate urgently, both times it was Dr. Hong who came in the wee hours of the night. Recently, I had a miraculous case that also required another great Pediatric Surgeon from that wonderful team do the same to save a patient from unnecessary delays. I am proud to say that one of the members of our community, Dr. Sam Soffer is an outstanding member of that prestigious team of Pediatric Surgeons at Cohen Children’s Medical Center.
The surgery required for Pyloric stenosis involves dissection of the muscle that constricts the pylorus. In about an hour, the Pylorus was back to its open position and the baby had an amazing recovery. The baby spent another 24 hours in the hospital for observation and was home before Shabbos.
I started the new year full of thanks to the Almighty for saving the precious baby from any harm. Out of curiosity, I searched and saw some videos online that showed the Laparoscopic procedure for Pyloric Stenosis. Hearing the stories of one of the mothers from Virginia, I realized how fortunate we were. Her baby was in and out of her doctor’s office and E.R.’s and continued vomiting for a week before he was finally diagnosed with Pyloric Stenosis. With great Divine Intervention, our baby was back to himself in less than 72 hrs.
I pray that the New Year should go smoothly for all of us, without the need to visit the Operating Room. Let all the right thoughts, the right people and the right actions come our way. Let us be guided to make the best decisions. And let us all remember to listen to the wise words of our Bubbies!
Wishing you a Happy and Healthy New Year
David Elazar Simai M.D.