"Your next patient is ready, Dr. Cohen," the medical assistant said, placing a three-inch-thick chart on my desk. Like all the other infants I saw that morning, the boy was considered at high risk, and it is my job to oversee follow-up care for such patients after they leave the neonatal intensive care unit.
Now nine months old, the boy had been born very prematurely, weighing 1,400 grams—just over three pounds—at 31 weeks. According to the discharge summary, he had had mild respiratory distress syndrome, which results from immaturity of the lungs; it is one of the common complications of prematurity. But he had escaped the other major problems of premature infants, like sepsis (bloodstream infection), necrotizing enterocolitis (a serious and potentially fatal intestinal disorder), and intraventricular hemorrhage (bleeding inside the brain). When he was discharged, he was in very good shape.
Over the past eight months at home, however, he had not had an easy time. The chart notes told me that he was being treated for persistent gastroenterological reflux. Although this condition in infants is usually benign, it can sometimes cause recurrent vomiting, irritability, and failure to gain weight.
"I'm glad we also have an appointment with the gastroenterologist today," his mother said, with a worried look, "because the reflux is getting worse. He's been fussier for the past couple of weeks, and he's been vomiting much more often. He just doesn't seem like himself."
Skull of a 25-year-old man with hydrocephalus.
From the Hunterian Museum of Royal College
of Surgeons.
When I examined the baby, he appeared uncomfortable, and his head looked too big: The upper part of his skull appeared out of proportion to his face. That was a red flag. The rest of his examination was fairly unremarkable, although he wasn't as playful and interactive as I would have expected for an infant his age. The therapist then did a developmental assessment, which consists of playing with the baby and observing how he manipulates toys, solves simple puzzles, and so forth. Her findings confirmed that he was lagging in all areas, even after correcting for his preterm birth. The lag was particularly puzzling because the boy had done so well as a newborn.
While the therapist was doing the exam, I went back and looked at the baby's growth chart. His height and weight growth were fine, but when I plotted his head circumference, my jaw dropped. I repeated the head measurement after he was finished with the test, and I got the same number.
Up through his last visit to the pediatrician, at six months, the boy's head circumference had been following the curve between the 25th and 50th percentile. Today it was above the 95th percentile line. That was alarming. The baby's recent increase in vomiting and fussiness might have originated not in his stomach but in his head. I suspected that he had hydrocephalus, a condition in which increased cerebrospinal fluid squeezes the brain against the skull. His symptoms and his developmental delays might have been getting worse because of the increased pressure.
