Monday, February 2, 2009

Evening Update (Monday 2/2)

One of the speech therapists broke the news to Carolyn today that infants who have been on NG tubes for three or more months almost always lose their oral competence and develop oral aversion. In these cases, babies can't stand to be fed by mouth (either via breastfeeding or with a bottle) and need a tube directly into the stomach to get nutrition. They'll need this so-called "g-tube" for about a year in most cases while speech therapists and their parents work to convince the child to use its mouth. Carolyn and I have noticed that Max hasn't used his pacifier since the Maalox dose a few days ago. Max will be getting a full oral assessment tomorrow, but we had already resigned ourselves to going home with a g-tube. The good news is that it's not our fault. Max was fated to lose oral competence thanks to his tube feeding. It was an unfortunate side-effect of all of the medical crises Max has endured; had his parents sat at his bedside round the clock with a pacifier he would still be where he is now.

I waylaid the pediatric GI specialist who came down to assess Max's reflux disease. I asked her several remedial questions about reflux. Perhaps she was a bit taken aback when I insisted on sitting down with her to talk about Max and my first question was "What is reflux?" But as we said in grad school, the great ones figure it out from first principles. I want to try to understand the anatomy and physical process at work before evaluating the proposed medical and surgical solutions. She had been brought down to consult on Max's medication. She felt that there was more to be done with medicine before we started thinking about surgery.

By coincidence the pediatric surgeon, Dr. C., was lurking around at the same time. (He was checking up on another surgical candidate.) He's the one whose knife Max has escaped twice now. With the certainty that Max will be getting g-tube, Dr. C. will finally get to work on Max. However, as we were talking, Dr. C. made the point that he has to be convinced to operate on infants by showing me the heels of his shoes. "They've been worn down because I will only operate on a baby after I've dug my heels in." So no-one is rushing Max to get the Nissen procedure (the standard surgery for reflux). I asked him if he is as reluctant to carve the Thanksgiving turkey. It turns out his family doesn't celebrate Thanksgiving, perhaps because it involves so much cutting.

When Carolyn got to the NICU this morning Max's clothes were fairly wet: he had thrown up his morning vitamin dose again. For the rest of the day he seemed to do well. When I saw him in the evening I thought he looked uncomfortable, because he was grimacing and waving his arms around, but a couple of passersby said that he was fine. (There's no privacy in the NICU.) Max does seem to do better when he has gravity helping keep his food down, so the NICU team installed a "wedge". This is exactly what you'd imagine: an enormous inclined plane that keeps the baby at a 45 degree angle (Max's is blue). To combat the tendency of infants to roll down hill, the wedge also comes with a basket into which the baby is inserted.

The pediatrician I spoke with today confirmed that proteins in many foods travel across the breast milk and can irritate infants. The number one food they advise cutting out is anything with cow's milk in it. Carolyn loves milk, but long ago gave it up. More recently, she's completely cut out cheese and other dairy products. I saw her staring longingly at a gummed-on piece of string cheese discarded by Felix. We're all making sacrifices.

Max had a great physical therapy session today. Carolyn said that he controlled his breathing and remained calm throughout. He was bright-eyed and alert. He turned to follow noises, toys, and faces. He grasped for a toy and he was lifting up his head and neck. Physical therapist A. was quite happy with his performance and said that he did "great".

I've mentioned my crackpot theory that babies are hardwired to follow faces, and that this is why so many toys have a face represented on them. One of our favorite toys is a friendly fish, which features a happy smile. Before Carolyn left to grab a bite of lunch, she left the fish within Max's reach. She took a cameraphone picture of the scene that she found when she returned.

Clutching the fish