The message on the pager caught my attention just as I was about to leave for my Sunday morning rounds at the hospital. I was on call for all the pediatricians in town this weekend and had a busy morning ahead of me. I called right away. A message like that could be anything from a stuffy nose to a severe respiratory problem.
“Hello, this is Dr. Cohen. What’s going on with your baby?”
“I don’t know. He seems to be breathing funny.” She didn’t sound panicked.
“Is he having trouble breathing? Is he turning blue?”
“No, it’s just that he’s making a kind of funny noise when he breathes, almost like he’s gasping or something.”
“Is he doing it right now?”
“Well, no, it seems to come and go. He’s been doing it since early this morning.”
After a few more questions, I decided that she didn’t need to call the ambulance, but I did need to see the baby as quickly as possible. I told her to bring him to the emergency room and ask to have me paged.
As I drove to the hospital, I thought about what might be troubling this infant. He might have pneumonia, or he could be wheezing from asthma or bronchiolitis, an inflammation of the lower airway. Choking on a foreign object could also obstruct the airway. Or maybe he had some systemic illness that was affecting his breathing: congestive heart failure, for example, or overwhelming sepsis. I needed to see him to sort this out.
I was treating a sick baby in the nursery when Matthew arrived. The nurse advised me that the boy appeared to be in distress, so I asked the emergency room doctor to see him first. By the time I got a chance to see him, Matthew had just had his chest X-ray taken. I glanced over and saw a pink and alert 1-year-old who appeared to be breathing normally. I turned my attention to the X-ray, which was completely normal.
“Hi, Mark.” Sarah Costello, the emergency room doctor, joined me. “I went over the boy pretty thoroughly, and I really can’t find anything. The parents say he’s been having this funny breathing intermittently—they say he did it over in X-ray—but I haven’t seen anything unusual. He looks great to me.”
I thanked Sarah and went into the examination room. The parents were in their thirties, and Matthew was their first baby. Joan had been an accountant before her pregnancy, and her husband worked for the county government. They looked concerned, but not panicky. Joan was holding Matthew, who had fallen asleep. I did a thorough exam and, like Sarah, found nothing unusual. “Dr. Costello tells me he started doing this in the X-ray department,” I said.
“That’s right,” Joan replied. “But the strange breathing happened when he was lying down. After the X-ray, when they sat him up again, he stopped doing it.”
I perked up. “And you said it was like he was gasping?”
“Yes,” she said, “like this,” and she demonstrated a kind of quick panting or gasping pattern of breathing.
Symptoms when he was supine but not when he was upright. I suddenly wondered if Matthew was having gastroesophageal reflux. In this syndrome, the gasping could be a manifestation of pain—not necessarily respiratory problems. Although the condition is not typical in 1-year-olds, the diagnosis seemed to make sense.