Bird

Driving home on the freeway today I was closely tailgated by a car whose occupants flipped me the bird - probably because I had done the same to them; I hate being tailgated - and then pulled up alongside me and mouthed unkind words to me. You can imagine what the words were. They were two young men, in their late teens or early twenties, and it struck me that they were probably very much like the fathers of many of my patients.

In a way I feel sorry for these guys. I know they are raised in less than optimal circumstances. They don't have nice homes, their parents probably didn't read to them much, and they were probably spoken to harshly as little kids. I've heard the way some of my parents speak to their young children. Also, I'm thinking there were probably not a lot of positive male role models for these kids as they grew up. Their car was pretty old and crummy and there's a good chance their vehicles will remain that way throughout their lives.

But another part of my brain wasn't so charitable and just thought of them as punks. They likely won't have or haven't had the modest amount of perserverance it takes to finish high school - less than 30% of the kids in my town who start high school finish it in four years - so will probably have crummy jobs, or no job, for much of the rest of their lives, . They think little of fathering children and expect the woman to worry about birth control, babies, and sexually transmitted diseases. They'll adopt the attitude that they are owed respect, even though they haven't done anything to earn it.

There's probably some truth in both the ways I think about them. I long ago reconciled myself to the fact that some of my patients today are tomorrow's reprobates. I take comfort, though, in the knowledge that some kids beat the odds and turn out well. Besides, everyone deserves some dignity and respect, just for being human. But I've got to stop giving people the finger, before I get shot or run off the road.

Cheesy

Today is a departure from our usual fare. Maria of intueri.org has organized The Literary Cheese Wheel, challenging some of us to write the cheesiest, dorkiest piece we can about one entity meeting another. For some reason, I took her up on it. Here goes:

Sperm Meets Egg

"Hey, big gal, you beautiful, bouncing piece of protoplasm, can you let your force field down so I can feverishly fertilize you?"

"Hi there, little man, I've had a million other guys like you ask me the same thing. How do I know you're the right one?"

"Just look at me! I'm cute and all my chromosomes are in the right place, with no extra little bits hanging around. And I really like your curves...will you be mine?"

"Hmmm, you do seemed lined up well and you have a really nice tail. Okay, you won the lottery! Walk those juicy genes my way, handsome."

"Whoa, not so fast, little lady, I have some questions for you now. How do I know you won't split in two after a couple of cell divisions and make me into twins or triplets? The world can only handle one of me at a time."

"You gotta have faith, man. I'm a one sperm per person kind of gal."

"Okay, here goes.... wow, it is really cool in here! Who does your decorating?"

"Enough chitchat, boyfriend, it's time to ride down that big Fallopian freeway. Let's multiply while we ride!"

"I'm with you, pretty mama. Can't wait to divide!"

****

Overheard 3, 6, and 9 days later: "Are we there yet? Are we there?"


P.S. Grand Rounds is up somewhere....oh yeah, it's at Medviews.

Possibilities

The father and I stood looking at his newborn baby. The baby was born full term by an emergency caesarean section for a prolapsed cord, which is when the umbilical cord comes out, at least partly, before the baby. The baby was breathing rapidly, but would be okay in a few hours. We didn't have much history on the mother because she had been rushed to surgery shortly after coming to the hospital and was now snowed with general anesthesia. All we knew is that she admitted to using cocaine, the last time 4 days ago. I was getting some more information from dad, and so far had found out that mom had 5 other kids who lived with the mom and this father. I asked him about the mother's prenatal care; she had none.

"You see," said the dad, pausing a moment, "she really wanted to abort the baby, but we didn't have enough money, and every week the pregnancy went further the price of an abortion seemed to go up a couple hundred dollars." Dad seemed like a real nice guy,very perky, very knowledgable about his kids, and very happy with the baby, which is just a bit paradoxical when you hear him saying they wanted to abort the baby.

Mom and baby turned out to have cocaine in their urine; we consulted Protective Services regarding placement of the baby: home with mom, foster care, or some other arrangement? Dad claimed paternity, and Protective Services said we could discharge the baby to his custody. Since he and mom lived together, along with her other five kids, it was sort of the same as discharging the baby to her. I didn't feel too bad about that, though, because dad really seemed to have it together.

I saw mom today in the NICU, six days after the birth, shortly before the baby went home. Unlike dad, she looked wasted and weary. Her skin had the little dark pockmarks I've seen before in drug users. I think they come from "skin popping" cocaine, shooting it just under the skin. She was holding her baby, and I couldn't help but wonder what she was thinking. Was it about what might have been - or not been - if she had more money?


P.S. Radiology Grand Rounds is up -check it out.

Denial

I took care of a full term baby last week, for a relatively minor problem, whose mother said she didn't know she was pregnant until she delivered or shortly before. Perhaps as a male I have no right to comment on this, but it seems to me to be pretty implausible. Didn't you feel the baby move? He didn't move the whole time. What about your lack of periods? I had bleeding throughout the pregnancy. And the weight gain? Well, I guess in our society it's not so unusual that someone gains 40 pounds over nine months.

Like most health care professionals who come in contact with obstetrics, I have seen this phenomenon many times before, and I always wonder where the level of denial is. I suspect that some who claim they didn't know they were pregnant really do know it but find it convenient or easier to deny it. The frightened single teen who just doesn't know how to handle telling her parents comes to mind. Others perhaps know that something is afoot but deny it to themselves. Then, maybe, there are those who have mental illness that makes them not recognize the pregnancy. Finally, there are probably some who really just don't figure it out that they are pregnant, although I suspect that's a minority of pregnancy deniers.

I guess I should be glad that this woman didn't continue to deny it after the baby was born. Now and then you hear about parents trying to flush a newborn down the toilet or throwing them in the garbage, although most of the time that's probably not a denial but just an act of desperation.

This mother had a diagnosis of schiziphrenia, although you sure wouldn't know it from talking to her. She seemed very lucid and rational. This was her fourth pregnancy, and it turns out it was the second time she didn't realize she was pregnant, which I guess makes her a serial pregnancy denier.

P.S. Shinga has asked me to remind people about the next Pediatric Grand Rounds. Submit your post to him by July 1, 1500 London time, at breath dot spa at googlemail dot com.

Discrimination II

I don't mean to overexpose the topic of when it's permissible to resuscitate or not resuscitate a premature baby, but there were enough interesting comments on my last post that I thought I'd go over it again. It seems to interest people and it is certainly relevant to those of us who work in the neonatal field. Plus, sometimes I have trouble thinking of what to write about, so this way I can save some other topics for another day.

Dear readers, I feel I must gently and good naturedly take you to task. Although the comments to the last post brought up interesting aspects of the topic, there were two central questions in the post, two issues that are the crux of the matter, that no commenter ventured to specifically answer. Those questions are:

1. At what gestation is it permissible to not resuscitate a premature baby? In other words, at what rate of survival and disability is it permissible to not resuscitate a premature baby? I know it's hard to give a specific number, yet that is what neonatologists are required to do at times, especially if there is a disagreement between the parents and neonatologist about resuscitation.

2. Is it age discrimination to say it's okay to let a newly born 24 weeker die, given that their survival rate is 55 - 60%, when we would not allow that if it were an older child? There seems to be something about the extremes of life ages, at the very beginning and the very end, when it is acceptable to let someone die, when we wouldn't do so if it were, for example, a 10 or 20 or 30 year old. A 90 year old woman with cancer that has a 55% chance of cure with chemotherapy? Most people would find it acceptable if she opted to forego treatment, preferring to die instead of undergo the hardships of the cure. Similarly, many think it's okay to not aggressively resuscitate a 24 weeker when they are a few seconds old. But we would really wonder about a 25 year old woman with cancer with a 55% cure rate if she didn't opt for treament.

One commenter - Ariella - said it was legally and ethically wrong for me to not respect parents' wishes if they didn't want resuscitation done on a 24 weeker. I appreciate her opinion, but Ariell, surely somewhere there is a survival rate at which we must resuscitate the baby even against the parents' wishes. What is it?

Finally, I just want to reiterate what Becca said, that there is a difference beween functional impairment and quality of life. Very true - people with disabilities can have an excellent quality of life, even if they cannot do some of the things we think are important.

P.S. Last night I watched the movie "The Ringer" on dvd. I recommend it, especially for anyone who thinks that people with disabilities don't have a good quality of life.

Discrimination

This past weekend I talked to a mother who was 24 weeks pregnant and had already broken her bag of water, making it fairly likely that she would deliver soon. We are frequently asked to speak to such moms prenatally. I told her about the NICU, about the prematurity of all the organ systems of the baby and what that means in terms of care, and about an estimated length of stay. Most importantly, I discussed survival rates with her and the chances of disability in survivors, and her thoughts about resuscitation of her baby. She said she wanted everything possible done for her baby.

Twenty-three and twenty-four weeks gestation are sometimes called the border of viability, because these are the earliest gestations where reasonable numbers of babies begin to survive. At 23 weeks the survival rate is about 30% and at 24 weeks it's 55 - 60%. Approximately one-quarter to one-third of those survivors will have a significant disability. Considering the survival and disability rates, many people think we should give parents the option of whether they want their baby resuscitated if born at those gestatioins. I don't have too much of a problem with that in a baby at 23 weeks gestation, but I personally find it hard not to resuscitate a 24 weeker. If a parent of a 24 weeker told me not to resuscitate her 24 weeker but rather let her die, I'm not sure I could respect those wishes.

I think we can all agree that at some gestational age all babies should be resuscitated and given life support (if necessary), regardless of the parents' wishes. For example, if parents of a 30 weeker - when the survival rate is greater than 95%, with most of the survivors without disability - said not to resuscitate their baby but let him die, just about everyone would agree that we should resuscitate that baby anyway. Similarly, if the parents of a 20 weeker - when there is no chance of survival - requested resuscitation, almost everyone would agree that it is acceptable for the neonatologist to refuse that request. But at what point in between does it become okay to not do as the parent wishes? Is it at 25 weeks, when the survival rate is 70%? Or 26 weeks, with a survival rate of 85%? At 27 weeks, with a rate of 88%?

Personally, I think it's tough to not resuscitate a baby when he or she has a 55 - 60% chance of survival, and I'm glad that in the population I work with nearly everyone wants everything possible done for their baby. (Most want everything done at 23 weeks, too.) As I mentioned in a previous post, if a, say, 10 year old had a disease with the same survival and disability chances of a 24 weeker, many people would want to call Protective Services to force treatment if the parents declined treatment. So what's the difference between that 10 year old and the 10 second old 24 weeker? The difference is age; it sounds like age discrimination to me if you'd allow no support for the baby but not for the older child.

This discussion can get hugely complicated; we haven't even mentioned things like quality of life for people with disabilities, or costs of treatment, both financial and emotional. I just think that sometimes we have to stick up for babies' rights.

Error

A few weeks ago a pregnant woman was killed by an overdose of magnesium sulfate at a hospital in south Florida. An 18 year old woman came in " seven months" pregnant in preterm labor. Magnesium sulfate, a drug commonly used to attempt to stop preterm labor, was ordered and given. Unfortunately, instead of getting 4 grams as ordered, the mother was given 16 grams. She developed cardiorespiratory arrest and died, in spite of resuscitation efforts. Doctors performed a caesarean section and delivered a live baby who is hospitalized in the NICU.

Hospital officials said the error was made by one nurse who simply gave an incorrect dose of magnesium sulfate. Like most people who read this story, I have tremendous sympathy for the family of that woman and child. But the person who I can't get off my mind is the nurse who gave the overdose, for whom my overwhelming emotion is also one of sympathy.

Like most doctors and nurses, I have made mistakes during my career. But I cannot recall making such an obvious error that so directly resulted in a patient's death. It is almost mind boggling to think of what must be going through that nurse's mind. How can she live with the knowledge that she caused a woman's death? Is she having suicidal thoughts? What defense mechanism can she employ to let her live with herself? She is apparently an experienced, excellent nurse. Anyone can make mistakes. Could that have been me making such an error? Am I a better health care provider than her, or just luckier?

My hospital has been participating in a perinatal safety project run by the Institute for Healthcare Improvement (IHI). The IHI would blame not so much the nurse here as the system or process. Every process that may result in danger to a patient, such as giving magnesium sulfate, should have some redundancy and safety checks built into it. Maybe more than one nurse needs to check the dose or IV rate; maybe there need to be maximums on how much magnesium sulfate can be put into one IV bag; maybe some other process change is needed. But safeguards are needed for everything in medicine, to prevent the one time in a hundred or a thousand that someone makes a potentially deadly mistake - not only for the health of patients, but also for the emotional health of medical workers.

P.S. Pediatric Grand Rounds is up at Unintelligent Design.

Pokes

I stuck myself with a needle from a patient the other day. Rats. I was suturing an umbilical catheter into place - think of it as a big IV in the belly button - and accidentally poked the suture needle into my finger. What a pain - not because it hurt much, but because it meant I had to go to employee health and fill out a million forms, get hepatitis and HIV labs drawn, and wonder whether the mother of the baby had any of those diseases. Unfortunately, she had no prenatal care so we didn't immediately know her status regarding them. I went to her room and asked her about things like IV drug use and hepatitis. She was very nice and denied any of those things. More importantly, her labs came back negative for hepatitis and HIV.

It reminded me of a pediatrician friend of mine who poked herself with a needle from an AIDS patient in the mid 1980's. This was near the beginning of the whole AIDS thing, and we didn't yet have real good information on the risk of transmission of HIV by a needle stick. My pediatrician friend was breastfeeding her 8 month old baby at the time and had a decision to make. Should she stop breastfeeding because if she did contract HIV from the needle stick she could potentially pass it on to her baby through breast milk? Or should she keep breastfeeding, knowing its advantages and thinking, to the best of our preliminary knowledge then, that her risk of actually developing HIV infection was small?

Now that question would be easier to answer, because we know that the risk of acquiring HIV from a needle stick is small - my employee health friends tell me it's one to three out of a thousand - and because if we are worried about the risk we can take effective anti-HIV drugs until we're sure the person poked doesn't get HIV. But we didn't know those numbers back then and we didn't have good anti-HIV drugs.

My friend kept breastfeeding. I guess it was the right decision, because she and her daughter - now a college student - remain in excellent health. It's not the real risk of infection from needle pokes that bother health care workers; it's just the natural worry.

Reaction

It was just a small cut, a couple of millimeters long, on the tip of the baby's earlobe. At first glance it looked like the tip of a scissors had nicked it, but on closer inspection it appeared a fingernail or needle might have scooped out a little bit of flesh. It will probably heal without leaving too much of a scar.

Mother was livid. She examined her baby head to toe every day and knew that something had happened to the ear. Mom used colorful language and threatened bad things if anything else happened to her child. It didn't help that no one would fess up to doing it, so we don't know exactly what happened. It also didn't help that my partner on duty at the time, when called to see the baby, heard the mother complaining and took 45 minutes to actually go into the room and evaluate the cut. My partner then made matters worse by minimizing the whole thing, telling the mother it was really nothing and unimportant. Eventually, one of the baby's primary nurses and the nurse manager talked mom down.

There was a time earlier in my career when I would have been a little ticked at mom for that kind of a reaction. We deal with some pretty tough stuff sometimes in the NICU. Accidents will happen, and in the big picture we have done a whole lot more good for her 24 weeker than harm. But now I see it a little differently. For one thing, I know that when it's your own kid nothing, especially in a hospital, is unimportant. Also, I know that mom was probably mad not just about the cut, but about everything. She was mad because her baby was extremely premature and had been on a ventilator the past seven weeks; she was mad because her baby couldn't be at home and it was a pain trying to visit her while she also cared for her two toddlers; and she was probably mad because dad was in jail and although she was doing her best to keep him informed and the family together, it just wasn't easy to do so.

Life can be rough. I'll keep working on her baby's ventilator thing, but I don't know any cure for those other problems.

Vioxx

A few days ago NPR ran an interesting and remarkable story about Vioxx, a pain reliever that was withdrawn from the marketplace in 2004 by its maker Merck after a study showed that its use increased the risk of a heart attack. The main theme of NPR's story was that in fact there was data from a study already in 1999 that showed an increased risk of heart attacks in Vioxx users, but that information was not made public. The report placed much of the blame for this failure to report the increased risk on the data safety and monitoring board (DSMB) of the study.

A DSMB is a group of scientists who are not investigators in a study, but who are charged with periodically reviewing the data and results of a study, with the responsibility of stopping the study before its planned endpoint if the data shows that one group or another is being harmed or suffering an unusual number of deaths or injuries. In the late 1990's Merck was funding a study comparing Vioxx, an investigational drug at that time, with naproxen, an already approved anti-inflammatory drug. The NPR report charges that the DSMB should have stopped the study early and reported an increased risk of heart attacks in Vioxx users, but they did not because, the report implies, some members of the DSMB, including its chairman, had financial interests in Merck. (Interestingly enough, the report does not come down too hard on Merck itself. The story almost seems to assume that a big drug company will be motivated by corporate greed and cannot be expected to do the correct ethical thing - such as stop a study if need be.) An FDA scientist estimates that between 1999 and 2004, 38,000 people died from heart attacks caused by Vioxx, deaths that could have been prevented if the information about Vioxx causing heart attacks came out in 1999 instead of 2004.

Far be it from me to wish to defend a corporation so motivated by profits that it withholds vital safety information. But I don't really know what went on in the heads of the DSMB members, and it is only fair to point out that a DSMB has a very tough job. When studies are planned, the number of subjects needed to show a certain degree of benefit is carefully calculated. Stopping a study early may mean that a benefit of a drug is not demonstrated because not enough patients were enrolled.

Not too long ago there was a large, multicenter study comparing premature newborns given hydrocortisone, a type of steroid, shortly after birth with those given a placebo, primarily to see if there was less lung disease in the hydrocortisone treated patients. The study was stopped early by its DSMB because the hydrocortisone treated babies had a higher chance of a gastric or intestinal perforation, basically a hole in the stomach or intestine. Some people were critical of the decision to stop the study early, fearing that a greater good of possibly finding a benefit to hydrocortisone treatment was nullified by a perhaps lesser safety concern.

If the study had proceeded to its conclusion, would we have found a benefit to hydrocortisone? Probably not. But there are two sides to everything - even if one of them is a large, hungry corporation.

Pain

The tiny baby was getting his PDA ligated, a surgery that involves making an incision around the side of the chest and tying or clipping off an open blood vessel that is very close to the heart. They were doing the surgery in a side room off the NICU, which is nice because then I could hang out in the room and keep an eye on things during the surgery. I was chatting with the anesthesiologist, who seemed a little nervous with this small of a baby, when he told me that he was using only one or two micrograms per kilogram of fentanyl as the anesthetic. I was appalled, because that is the dose of fentanyl we use for pain relief in the NICU. For anesthesia, you need about ten or more times that dose. In other words, this baby was having major surgery without real anesthesia.

This happened many years ago, in the early 1990's or late 1980's. Unfortunately, in the history of neonatology there have been many times when babies have been under anesthesized or not given adequate pain relief. It's a dark spot in our field, but fortunately now there is an increasing emphasis on pain relief. We're getting better at it, but there are still some problems.

The biggest problem with neonatal pain relief, as I see it, is that there are two opposing principles involved. One, we know that repetitive unrelieved pain is not good for babies and can lead to increased sensitivity to pain later in life. On the other hand, though, we know we shouldn't give treatments that have unknown effects on a baby's long term outcome. And there's the rub; we don't know what repetitive use of many of our analgesics does to the baby's developing brain. Does frequent stimulation of the opioid receptors in an immature brain change the formation of that brain and its pathways? It's hard to believe it doesn't, and not all of the data is reassuring.

One pain reliever used for newborns is sucrose, that is, sugar water. It's well established that a little bit of sucrose, combined with sucking on a pacifier, prior to a painful procedure offers pain relief. It probably works because the sweetness stimulates the release of the baby's own natural (endogenous) opiates. We're having a discussion now in our NICU whether we can use this routinely and frequently in premature babies, who can have hundreds of painful procedures like blood draws and IV starts done during their hospitalization. It sounds innocuous - hey, it's only sugar water - and some of the nurses want to be very liberal with it. But frankly, I'm a little leary of it; we don't have long term follow up information about what sucrose's repetitive use does to the immature brain. It may be only sugar water, but somehow it affects the brain - otherwise it wouldn't offer pain relief - and therefore, it seems, could affect brain development.

We could talk a long time about this topic, but this post is too long already. When in doubt, primum non nocere. First of all, do no harm.

Alternative

A few days ago our newspaper ran an article noting that an alternative medicine advocate was coming to town to give a presentation or sign books at a store. This particular alternative medicine practitioner strongly believed in cleansing the GI tract, apparently by eating properly and giving yourself enemas. I was too turned off by the article to finish it to see his exact methods.

I don't have much good to say about alternative medicine. I don't mind that it's alternative; what bothers me is that most of it is not evidence based. Some alternative medicine is evidence based, that is, has been shown in well done studies to be beneficial. For example, I think that acupuncture has been shown useful for certain types of pain, and that hypnosis has worked for some things, but most alternative medicine practitioners simply make unfounded claims for their treatment, or rely on the claim that it is "natural", as if that automatically infers magical properties upon it. Even when an alternative therapy is shown not to be helpful, it is still promoted. For example, a study published a few months ago showed that echinacea was not useful in the treatment of upper respiratory infections (colds), but it is still touted in and sold at health food stores.

Alternative medicine can be harmful, too, both directly (does anyone doubt that you can be harmed by too many enemas?) and by making someone forgo needed conventional treatment. When I was a medical student I had a patient who was a young man in his twenties who had Hodgkin's disease. Instead of finishing his conventional therapy of chemotherapy and radiation, he went to Mexico and tried laetrile instead. Unfortunately, while on the laetrile his Hodgkin's disease progressed and a tumor compressed his spinal cord, turning him into a paraplegic. He came back to our medical center to finish conventional treatment. His Hodgkin's disease would be cured, but he would be a paraplegic for the rest of his life.

Personally, I think we should do away with the terms "alternative" and "conventional" medicine, and simply describe medicine as evidenced based or not evidence based. If good evidence shows a medicine works and is safe, it doesn't matter if it's a natural herb or a manufactured chemical pill.

We could talk a long time about why people spend billions of dollars a year on alternative, unproven therapies. Maybe it's a failure of conventional medicine to properly attend to the emotional ramifications of physical disease. Maybe it's an almost innate tendency of at least some people to distrust the "establishment" method and try something different. Whatever it is, it's a huge waste of health care dollars, and we don't have unlimited amounts of those to go around. Ideally, we would take some of the money spent now on alternative medicine and use it to study the treatments, so we could keep the worthwhile ones and throw out the rest, but I don't see that happening real soon.

Dichotomy II

I wrote a few days ago about two mothers of 24 weekers, a nineteen year old and twenty-six year old, and how I enjoyed working with them. We hadn't seen much, though, of the fathers of their babies, and recently I found out why: they're in jail. One is in for a drug related offense, and we don't know what the other one is in for, but it's probably something serious, because he was originally threatened with a sentence of twelve years to life, but managed to plea bargain it down to a lesser time.

It's not unusual for us to see the fathers of our babies in the first few hours or days after the baby is born, but as the hospital stay extends, we often see them less and less, although the mothers keep coming. That could be because the dads are working, or maybe staying with the other kids while mom visits, but often it's probably because in our society the father can simply get away with being absent, at least more easily than the mothers can. I suspect that lots of books and Ph.D. theses have been written about the reasons for absent fathers.

It shouldn't surprise me that incarceration is one of the reasons for a dad's absence. A few years ago I read the discouraging statistic that it was more likely for a young black male in our city to go to prison than to college.

I have a similar dichotomy of feelings towards the fathers of our babies as I do towards the mothers. On the one hand, I am frustrated with the way they sow their seed and then don't take responsibility for their offspring. But I also feel sorry for them, because they grow up in an environment that seems to encourage failure as much as success. They are both the product of and contribute to the seemingly endless cycle of young single parenthood, poor education, lousy jobs, and poverty that permeate too many of our urban neighborhoods.

P.S. Seen on the T-shirt of a woman in our hospital: "I don't make mistakes....I date them."

P.P.S. Grand Rounds is up at the Medical Blog Network, and Pediatric Grand Rounds is up at Anxiety, Addiction, and Depression.

Syphilis

Syphilis is a weird disease. I practically never see anyone sick from it, at least not visibly sick, but yet often treat babies with it for many days in the hospital. That's because syphilis nowadays, especially in babies, is almost always diagnosed or suspected not by signs of illness but rather by an abnormal laboratory test.

Every mother is supposed to have a blood test for syphilis at or shortly before the time of delivery. The test detects the presence of antibodies to syphilis and the result is expressed as a a titer, e.g. 1:1, 1:2, 1:4, and so on. The higher the titer, the easier it is to detect the antibodies. A problem is that after someone has syphilis, the test for it can remain positive for years, making it difficult to know for sure whether a positive test is due to new infection or to old, previously treated infection. Sometimes by history we can sort it out, but other times we simply cannot. Since untreated syphilis can be transmitted to the baby in utero and lead to bad problems such as insanity or death, we err on the side of treatment if there is uncertainty of the diagnosis.

We currently are treating a baby for possible syphilis whose mother had syphilis in 1997 that was, as far as we can tell, treated adequately. Her syphilis titer in this pregnancy went from 1:2 originally to 1:4 and then 1:8 at the end of the pregnancy. Is this just some variation in the lab test, or new infection in the mother? The baby's titer is also 1:8. Is that just transferred old antibody from the mother, or is it real infection in the baby? We aren't sure, but the chances of new infection in the mother - and passing it on to the baby - are great enough that we did a spinal tap on the baby to rule out nervous system syphilis and are treating the baby with ten days of penicillin.

It can be a little tricky sometimes talking to parents about syphilis. Mom's usually embarassed, and you have to try to make them understand the antibody thing, then convince them to let you do a spinal tap on their seemingly healthy baby and keep the baby in the hospital for ten days of treatment. But I bet it's trickier for the mother to discuss it with her partner and other relatives. She almost has to either accuse her partner or herself of infidelity - no small thing - or else claim it's just laboratory variation in the antibody testing, which is pretty hard for one layperson to explain to another.

For crying our loud, don't sleep around, and if you do, use protection. Your baby might thank you for it someday.

Lorraine

A commenter on a post a few days ago - Dream mom - suggested I write a post about a "good" single mother, because, I think, I've complained enough about other single mothers. So I will, and then I'll lay off the topic of single moms for a little while.

"Lorraine" was 23 when she got married and started having babies shortly thereafter. She was mostly a stay at home mom, but sometimes worked part time as a secretary because her husband didn't make much money. Her husband died when she was 44, leaving her with 5 children, ages 7 through 20, and very little life insurance money. She went back to work, coming home every evening to cook supper for her family and negotiate disputes between her kids. Although she had one or two "dates" with guys, she never really again had a significant relationship with a man, nor did she engage in any relationship with casual sex. Her family was her life, but without a companion in life she was lonely and at times depressed. Her children turned out fine, and she enjoyed many grandchildren before she died at age 78.

Perhaps some of you have guessed that I'm talking about my mother. She was a single mother, and I know that there are many other good single mothers out there, single for all kinds of reasons, and that we shouldn't paint all single moms with the same critical brush. I also know that single moms who are young and not attached to their baby's father can be good moms. Currently we have two moms whose 24 weeker babies are across from each other in the same room. One is a 19 year old with her first baby and the other a 26 year old with her third baby, and it has been a delight to work with them and their babies. They are bright and involved and appreciative.

We also have a baby whose mother is 22 years old. This is her fourth baby after her seventh pregnancy. She now has two kids under the age of one year who are not twins. She also seems pretty nice, but what can I say? Do I have to explain my sadness at this situation? I doubt that any of her kids will say that they wish they had never been born, but still....can't she just use some birth control?