As I read the nurse's note in the infant's chart, an involuntary sigh escapes from my lips. A 9-month-old child who refuses to eat. This does not bode well for the first patient of the day. I glance at my posted schedule, already full for the morning session.
“Have I met you before?” I ask, introducing myself to the woman who stands in the middle of the examination room holding a pudgy blue-eyed baby in her arms.
“I don't believe so,” she says, awkwardly extricating a hand to meet my own. “We're relatively new to the practice.”
“I see,” I smile. “What seems to be the problem?”
“He won't eat,” she says. “He's refusing all solids, and I can barely get a 4-ounce bottle into him. I'm afraid he's going to dehydrate.” Her eyes well up with tears.
I snap a couple of tissues from the box on the countertop and offer them to her. “When did all this start?” I ask.
She dabs the corners of her eyes. “Five days ago,” she says.
“He hasn't eaten for 5 days?” I ask.
“Has he been sick? Any fever, vomiting, diarrhea?”
She shakes her head.
“When did he have his last stool?”
“And before that?”
“He's had his usual bowel movement every day, so far as I know.”
“Has he been having wet diapers? How many in the last 24 hours?”
She rolls her eyes; her lips move silently as she counts to herself. “I'm not sure, maybe 6 or 7.”
“Well, that's certainly not bad for a child that's refusing food and fluids. Let me have a look at him.”
The boy stares at me as I rest the diaphragm of my stethoscope against his chest. He smiles when I squeeze his belly. His nailbeds blanch with gentle pressure, then flash pink when released. The ears are clear, the mouth is moist, the throat is normal: no lesions, ulcerations, or exudates.
“How does he look?” the mother asks.
“He actually looks good,” I say. “Certainly no sign of dehydration on physical exam, and overall he's had a nice weight gain from his last visit.”
A new flood of tears erupts from her eyes. “What can I do to get him to eat?”
I hand her the box of tissues and motion for her to sit down. “So all this behavior started 5 days ago?” She nods her head. “Did anything out of the ordinary happen at home? Any major shakeups?”
“I left for Chicago,” she says. “I just got back last night.”
“And the baby...?”
“I left him with his father.”
“So his dad has been taking care of him while you were away,” I muse. “Does your husband work? How did he manage to take care of your son?”
“He has a full-time job, but he can work from home if he needs to. He's not as comfortable with the baby. I'm usually the one who cares for him.”
I nod my head. “So you're pretty much the one caring for your child at home. Do you also work outside the home?”
“No—I mean yes, I do work; but I run my own business out of the house. I had to go to Chicago for a business meeting. Things haven't been going so well. I'd like to quit, but right now money's tight. We can't carry the mortgage on my husband's salary alone. If I'd stop working, we'd probably end up losing our house.”
She pulls more tissues from the box, pushes up her glasses and dabs her eyes. “Don't mind me. I always cry like this ... new mom—you know.” A short laugh dies in her throat.
In his 1955 article, “The Doctor, His Patient, and the Illness,” Michael Balint wrote:
“A special form of the patient offering of an illness is that which is called the ‘child as the presenting symptom.’ In a large number of cases the scenario is when children, especially babies, are brought frequently to the surgery when in reality the person who is really ill is the mother or father.... It was agreed that in about one third of the cases in which children are brought to surgery by their parents it is the parents who need treatment.”1
At core, all pediatric problems are family problems that sometimes present in a different way.