Ear infections in infants

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How to diagnose a 9-month-old cranky infant: Showing clinical students some of my tricks

It was about 11:00 in the morning when we finally got to the patient. A mother had been anxiously waiting for us to see her 9-month-old infant who had been refusing to eat and drink. Few things bother mothers more than an infant who refuses to eat. Hours before arriving, I had talked to her over the phone.

A mother’s anguish

“My baby used to drink three bottles of formula every day. But now, he hardly drinks an ounce,” said the mother, her voice bruised with helplessness. “His nose is dripping nonstop, and he also has a slight cough,” the mother added to her list of complaints. “But he has no fever. I have been checking his temperature every minute,” she told me. “Let that not bother you so much. Bring him to my office, and I will figure it out,” I reassured the mother. 

The Physician Assitant students

That day, two physician assistant (PA) students were rotating in my pediatric office. So, I asked them to take the first crack at the case. It was day five day of their clinical rotation with me as their preceptor. During the previous four days, they watched me interact with patients and make diagnoses. Now, I thought, was a good time to let them try their budding skills. After all, skills are better built by doing rather than by watching. “There is a child and a pleasant mother in the waiting room,” I said to the students. “Go find out what is going on.”They briefly reviewed the chart, called in the mother and child, and led them across a short hallway to our favorite consulting room. After spending roughly 7 minutes with the mother and child, the students reported their findings to me.

What is your diagnosis?

“What is your diagnosis?” I asked when they finished presenting their findings to me. “Common cold,” said one student; the other agreed. Hearing that, I used my left ring finger to scratch a side close to my right eyeball and readjusted my neck and head in a manner that showed suspicion. For readers, a diagnosis of the common cold is made when a child suffers from a runny nose and a slight cough with hardly any other significant findings. So were the students right? Did they miss anything? Yes, they did.

Students miss stuff all the time. However, because they are still learning, they do not get penalized when they miss something in their diagnoses. Still, incorrect diagnoses are opportunities for teaching moments.

Suspicious

When I went back to see the mother and the 9-month infant male, I became suspicious of the students’ diagnosis. I felt that something other than a common cold must be going on for the mother to be so deeply concerned about the infant’s refusal to eat. Unfortunately, this depth of clinical skill only comes through knowing your patients and their families and gaining experience in the field, which my two students did not have. 

“Let us go see the infant,” I said after the students had presented to me. When we entered the consulting room, the mother was still sitting in one corner of my office, and she held the infant in her lap. “Good morning, Mrs. Gertrude,” I said. “Good morning, Doctor A,” the mother replied. She then retold me the story that the students had relayed to me minutes ago. While I was talking with the mother, my eyes were watching the infant. During that period, I could see that he periodically wiggled his body as if in protest. In an attempt to soothe him, the mother would pat his sides a little and bring him closer to her chest. “Oh! Since he has not been drinking as before, he might be hungry,” I said to the students and the mother.

“Did you bring any formula?” I inquired.

“Yes,” said the mother. She reached for a bottle from a bag, shook it a few times, and handed it over to the infant.

The infant gulped an ounce or two of the formula and was soothed for a period, but then he gave up drinking and began to fuss as if he was going to burst out crying. My thought then was that “hunger” was not the primary reason that the infant was fussy.

A cranky infant

Using one of my clinical tricks, I began to clap my palms in a musical rhythm to entertain and charm the infant. He turned and looked at me and my palms and was attentive for less than a minute before turning away, irritated. Something else must indeed be going on, I concluded. At this point, I pointed out to the students that this behavior qualifies for what clinical pediatricians call a cranky infant. “When you start practicing,” I told them, “you should be able to remember this demeanor that you witnessed today to remind you what a cranky infant looks like.”  

Holding Grudges

Well, a 9-month-old infant possesses a wide array of behaviors depending on where they are. Then, I explained to the students that certain conditions could account for the infant’s unfriendliness. First, it is not unusual for 9-month-olds to hold grudges against clinicians for the vaccines they received in the last 6 months. “Bear that in mind,” I said to them. What was different in this infant was that he was unable to put that suspicion aside and enjoy my playing initiatives. Stranger anxiety is a condition in which infants of this age show an aversion to strange faces (such as those of the students). Therefore, they could possibly account for the infant’s unfriendliness. But then again, that is not applicable here giving the complaints of refusing to eat, which began at home. While talking with the mother, I started to search for clues about why this infant was cranky and would not eat for his mother.

Dos and Don’ts, how the professionals do it

Separating a cranky infant from the comfort of his mother’s arm is looking for trouble. Following my request, the mother held the baby over her shoulders while I listened to the baby’s posterior chest with a stethoscope. Satisfied that the baby was not wheezing, I asked the mother to position the infant so that I could look into his eardrums. “Red right tympanic membrane,” I declared once when I was done checking his ear. “What was that,” asked the mother. I responded, “Max has an ear infection in his right side. Do not worry—I will make sure he gets better.”

“How serious is it?” asked the mother.

“Not that serious. Nothing that I cannot handle,” I reassured her.

“What’s next?” asked the mother.

“I have sent some amoxicillin and Motrin to the pharmacy for your baby. He will be fine.”

I hurdled up with the students after we left the consultation room. “You made it look easy,” said one of the students. “Well, remember I have been doing this for 33 years since 1986,” I said. “I wasn’t even born then,” said one of the students.

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