Futures

In a comment on my previous post, Ali asked "Do you ever feel your Herculean efforts to save these children are futile when you contemplate the futures they are destined for?" I know what she means, I think. She wonders if it isn't discouraging to realize that many of my patients will grow up to be "welfare moms" themselves, or drug addicts, or high school drop-outs, less than shining stars of society, just like their parents are. I do realize what they might be when they grow up, but nevertheless the answer to Ali's question is a resounding "No!"

For one thing, not all the kids will grow up to be just like their parents. Some of them will escape the depressing cycle of early single parenthood, inadequate education, lousy jobs, and poor self esteem. Some will make it through high school and college and become contributing members of society.

Even if they don't, though, I don't think we should judge a person by his or her station in society. People who are on the lower end of society - I don't really know how to describe them - even drug addicts, still have worth. They may be a drug addict with no productivity in life, but they are still someone's sibling, or child, or friend, and as such bring some pleasure into another human's life. They might not have a job, but they might have a great sense of humor and entertain their families at Sunday dinner, or have a good listening ear and bring comfort to another person.

But mostly, I don't mind taking care of babies who are destined for less than greatness simply because they are human beings, and I think every human being has some inherent worth. Humans are not just another animal. I can't explain exactly what makes them different from other animals, but something does, and we can never forget it. It's what makes us always take the loss of human life seriously. It's why we can never be flippant about decisions to remove life support. It's why every baby must be treated with dignity, regardless of whether they are perfectly formed or have severe defects like trisomy 18 or holoprosencephally. That doesn't mean we have to treat every baby born, even those with terrible birth defects, with heroic life support, but we have to take it seriously if we don't.

Ali, I know where you're coming from and don't mean to be hard on you in this post, but never for one minute do I think my efforts on behalf of any baby are futile.

Fiance

A relative of mine recently became engaged to be married, which means that I'll have to start calling her boyfriend her fiance instead of, well, her boyfriend.

There was a time, maybe 10 to 20 years ago, when it was common for single moms to refer to the father of their baby as "my fiance." It happened so often that we used to laugh about it, knowing that many of these "fiances" would never walk down the aisle together. I think that single moms called them that as a way of lessening the perceived stigma of single parenthood. It wasn't so bad to be unmarried and pregnant if you were planning on marrying the father.

Lately, though, it strikes me that I don't hear moms use the fiance word much anymore. The fathers of the babies are referred to as simply the "father of my baby", or sometimes as "my boyfriend". Once in awhile a father is referred to as "my husband", but with more than 90% of our babies born to single moms, that doesn't happen much. I wonder if the less frequent use of the fiance term indicates a differing perception of single parenthood. Certainly nationwide the percentage of babies born out of wedlock - that seems like such a quaint term, doesn't it - is increasing. Is it no longer as great a stigma as it used to be? Or am I reading too much into not hearing the fiance word?

I remember a social worker telling me that when she heard a single mother refer to the father of her baby as her fiance, she would always ask, "Oh, when is the wedding date?" knowing there would likely be none. Too cruel, too cruel.

Contradictory

"They said he would never come off the ventilator."

When I heard that the mother had said that, I just had to shake my head a little bit. How is it that parents can be so mistaken about what we told them? Sure, we told them their baby would likely be on the ventilator for a long time, but never come off? I know we didn't say that.

The mother was talking to our NICU's nurse manager. She was the mother of the baby whose arm had broken (see my previous post) and in the course of a long chat with the manager was getting some things off her chest. She also was a little miffed and confused because of how we had explained the cause of the baby's yeast infection to her. I had told her about the baby's prematurity and poor defenses secondary to that. My partner had mentioned that antibiotics can contribute to it (which is commonly thought to be true but recent evidence suggests it might not be). The mother saw these as contradictory rather than complementary explanations.

I can see to some degree how mother could be confused by that, although I'm sure our explanations included more than those two elements, but I really don't understand where she got the idea about her baby never coming off the ventilator. Was that her own fears changing her words as she processed them? As she got farther and farther away from being told the baby would be on the ventilator for a long time, did her memory fade and change "a long time" to "never"?

It's actually a fairly common occurrence, parents saying we said something we never did. I don't think it's malicious or intentional on their part. It's probably just another thing we can attribute to the stress people have when their baby is in an NICU. (Although I think there are some parents who unconsciously, or sometimes consciously, embellish their baby's story, perhaps to make it more dramatic. The number of times I've heard a parent say of a school aged child "They said he would never walk or talk" far outnumbers, exponentially outnumbers, the number of times I have actually said it.)

We'll just keep plugging away. I try to tell myself it doesn't bother me anymore when parents claim I said something I didn't, because I understand it and can rationalize it - but I really don't like lying to myself.

Fracture

At the beginning of her shift the nurse noticed the baby was not moving his arm much and asked me to check it. The baby, born at 25 weeks gestation 8 weeks earlier, was still on a ventilator and pretty sick. Examining the arm, I noticed some swelling and redness in the upper arm. Father, who was there with me, made the diagnosis the same time I did. "Hey, that looks like it's broken," he said. I had to agree, and an X-ray confirmed it.

I think every NICU has had a broken arm in a tiny premie at one time or another. The very premature babies usually have relatively demineralized bones, for a combination of reasons, and it's easier to break them than it is the bones of a term baby. On the other hand, most tiny premies get through their NICU stay without a broken bone, in spite of demineralized bones, so if a baby has a broken arm, something has gone wrong. We don't know exactly when this baby broke his humerus. I suspect it occurred when he was being turned over or something like that, and perhaps his arm caught under him and snapped. The nurse wouldn't have even known it happened until the swelling started or they noticed it wasn't moving.

This was discouraging, to say the least. The parents were understandably upset and immediately started talking about transferring their baby to another NICU. I sighed to myself. We had maintained a good relationship with them through the baby's rocky NICU course so far, keeping them informed and being open with them, and it was disappointing to see that dissolve so quickly. Interestingly enough, they didn't seem that upset about the actual fracture itself but were angry that it hadn't been noticed and reported sooner (although, since we didn't know when it occurred, we don't really know how long it went unnoticed.)

It goes to show, I think, that we can never let our guard down in the NICU. You have to have a certain degree of compulsiveness to do well there. We can grow comfortable working there - we have to, or we couldn't stand it - but we cannot become complacent. You have to always be careful, whether you're writing IV orders, calculating an antibiotic dose, adjusting ventilator settings - or merely repositioning a baby with demineralized bones. Part of me is a little ticked at whoever did this for letting his or her guard down, but also, I know we all make mistakes.

The fractured bone is lined up nicely and the baby's arm should heal well. In fact, compared to the baby's lung and infection problems, plus his risk for neurodevelopmental problems secondary to prematurity, the fracture is a relatively minor thing. But for now, it takes center stage for the parents and therefore for us.

Appropriate

I was feeling down. A patient at work who should be doing better wasn't, and a good relationship with a set of parents had gone a bit sour, partly through someone else's fault, but partly through my own.

On another front, the grocery store was out of a number of things, and I couldn't find any pecan rice to make my pecan rice turkey stuffing, although maybe that didn't matter because I couldn't find the recipe for my pecan rice turkey stuffing either. Now, in the fancy produce market, the "fresh" turkey I had ordered and just picked up was mostly frozen, with only a limited time before Thanksgiving to thaw it, and clementines, those seedless tangerine-like things that are a favorite fruit of mine, were outrageously priced at$7.99 per crate. Life, I thought, is a bear.

Then I heard someone say, "Excuse me, but aren't you Dr. Neonatal Doc?" The speaker looked familiar, but I couldn't quite place her or put a name with her face. "I'm Jane Doe," she said. "I worked in the special care nursery when you were at St. Mordecai's Hospital." I remembered, and we had a nice chat. She was now enjoying retirement.

Before we parted, she said to me "You know, I just wanted to let you know that I thought you did a great job in the nursery." I thanked her, and she went on. "You were always so," she paused, searching for the right word, "so...appropriate." She made my day. Then, on my way out of the market, I found a bottle of a favorite German wine, a Piesporter, for the ridiculously low price of four dollars per bottle. Things were really looking up.

Now, as I think of it, I'm not certain what it means to be appropriate, but I'm sure it's better than being inappropriate. I think I'll have a good Thanksgiving, even without the pecan rice.

Creative

About a week ago I wrote about a pair of 27 week gestation twins who concerned us because of questions regarding the mother's parenting skills. Unfortunately, it turns out that we had good reason to be worried.

One week after going home one of the twins developed some apnea, a breathing problem where kids just sort of skip taking breaths. The mother brought that baby to the hospital and the baby was admitted. So far, this is not too unusual, since premature babies often need to be readmitted to the hospital after discharge. The real problem comes with the second twin. The baby was on iron drops for anemia, and there had been some problem with the bottle the iron originally came in, so someone in the home had put the iron into a regular baby bottle and put it into the refrigerator. While the mother and father were in the emergency room with the first twin, someone else in the home fed the bottle containing the iron to the second twin, apparently thinking it was juice or something. That twin developed iron poisoning and was rushed to the hospital and put on a ventilator. Her iron level in the blood was over 1,000; it's considered severe poisoning if the level is greater than 350.

When we heard about this in the NICU, we hardly knew how to react. We were frustrated with the situation, of course, and wanted to be angry at someone, but at whom should we be angry? You can't really be angry at someone for being stupid, can you? Also, it's not clear who did the damage here. Who put the iron into a baby bottle - stupid enough - and then put it into the refrigerator? Who fed it to the baby? There are several siblings of the mother in the home, and some small children as well.

Sometimes it just seems so hopeless. People are so creative in their stupidity that there is no way to anticipate and thereby prevent every possible thing that can go wrong. We can, I guess, only try to prevent kids from going to bad homes. Maybe we're a little angry at ourselves for letting these kids go to this home, but realistically Protective Services cannot and will not remove kids from this kind of home if nothing has gone wrong. We'll have to wait to see what happens now.

P.S. Check out the new pediatric grand rounds at Aetiology.

Adopt

A friend asked me if I wanted to adopt 4 year old twins. A boy and a girl, they were put into foster care as newborns because of an incompetent mother. I'm not sure what her story is, whether it's drugs or what, but after four years of giving her time to get her act together, the court finally terminated her rights to the kids permanently, meaning the kids can be adopted now.

The children have been in the same foster home since birth, the home of a middle aged nun. She has by all accounts been a wonderful mother to them, and they are thriving. However, the mother doesn't want to adopt them, since she has some health problems herself, and the Catholic order to which she belongs probably would not let her adopt the children permanently anyway. Apparently they are worried about their long term responsibility if if she adopts them and then something happens to her.

I feel terrible about the prospect of these four year olds having to be taken from the only home they have ever known, to be raised by current strangers. I want to be sure they end up with a great family that will deal with and minimize the trauma that will be for them, but I can't agree to adopt them myself.

I like kids and have enjoyed raising my own kids (and still have some of that to go, which is okay with me), but now I'm at a different stage in my life. I look forward to doing things I couldn't do with small children, like maybe going on a medical relief trip (maybe Doctors Without Borders?), reading more novels, attending more sporting events, and just generally having more free time. I'm also not at all sure I could give adopted kids the same commitment to parenting I did for my own, and if I can't be a good parent, I don't want to be one at all.

Also, these kids have a quite different genetic make-up than my own. Will they, like their mother, be prone to live chaotic, maybe addictive lives? That would be very difficult to handle. Finally, and I'm hesitant to admit this, when I really question myself I wonder if my reluctance has anything to do with the fact that the kids are black and I'm not. I don't want to be prejudiced, and I try not to be, but when I imagine the kids being white, I'm embarrassed to say I have a slightly different feeling towards them - but I still don't want to adopt them.

I just hope they don't end up being passed around from home to home in the foster system. Anyone want a couple of nice kids?

P.S. I'm sorry this post is late, but my computer got into a spat with our internet service provider, and I was without computer service for awhile.

Entertainment

The other night I watched Masterpiece Theater on PBS, playing a show starring Helen Mirren as Jane Tennison, a British policewoman investigating a death. The show was well done, but it had to be one of the most depressing programs I have ever seen. Name the depressing entity, and it had it: murder, teen pregnancy, possible incest, alcoholism, loneliness, death by cancer - and this was only part one. I can hardly wait to see what downers they put in part two. I kept waiting for a commercial to give us a break from the gloom, but, this being PBS, one never came.

I don't really understand why people are drawn to this kind of entertainment. I've never felt the need to look to entertainment to fulfill my quota of sad things, because I get enough of it at work. Don't get me wrong; neonatology is generally a happy specialty, and I don't deal with death and destruction everyday, but I see it enough that I don't need to see much more of it on TV or at the movies. Maybe people in other jobs feel the need to experience this stuff vicariously in their free time.


I also recently saw "Movin' Out", the Broadway style musical based on the songs of Billy Joel. I was expecting a musical play, but after the first few songs I stopped wondering when the speaking parts would come and realized it was a song and dance revue, almost a modern ballet. The band was tremendous, and I still enjoyed it, although if they hadn't put a two paragraph synopsis of the story in the program I wouldn't have been able to figure it out, except that it had something to do with love and war. (That's what I want to do for a second career: write two paragraph stories for Broadway shows and get paid a ton of money for it.) In an unwitting commentary on American sensibilities, the producers had no qualms about having the dancers simulate sex acts on stage but thought it necessary to omit the verse in "Captain Jack" that contains the word "masturbate."

I'll keep trying to find the perfect entertainment. Has anyone seen any good romantic comedies lately?

Smushed

With her history of no prenatal care and 10 previous children, plus her cachectic build and the pock marks on her skin, she might as well have had "drug user" stamped on her forehead. I was called to the delivery because there was no prenatal care, and after the baby delivered and things calmed down a bit I went to talk to her.

"Hello, I'm Dr. Neonatal; I take care of babies after they are born."
"Hi," she said, "How are you?" I liked her already; the "how are you" was a nice touch from her, something I don't usually hear, understandably, from mothers who delivered a baby about 10 minutes before. After the pleasantries, I got down to business.

"How many kids do you have?"
"10."

"Are they in good health?"
"Yes."

"Do they live with you?"
"The older ones do, but the younger ones are with their father." If kids don't live with their mom, there's a high likelihood Protective Services has removed them.

"Have you ever had Protective Services involvement?"
" Yes." She was being remarkably nice and cooperative, but that soon stopped.

"Did you take any drugs during your pregnancy, like marijuana or cocaine?"
"Ohh, ooh." She started moving as if in pain. The OB resident rephrased the question, "Did you use any crack during your pregnancy?" Again the question went unanswered.

It was no surprise when her urine drug screen came back positive for cocaine and opiates, and when I called the case into Protective Services the worker said "Oh, my goodness gracious" when her previous history of protective services involvement came up on the computer screen. I couldn't help but like the woman, though, even though her lifestyle was pretty much the very antithesis of mine. She was so nice, and her baby was so cute, and she was so thankful to me, even when I explained that the baby would have to stay in the Special Care nursery instead of with her until P.S. checked out the home. She understood, having been through the drill before. It's one thing I like about this job: Sometimes you meet the nicest people at the most unexpected times and places.

On my way out of the special care nursery, I saw a spider on the wall. I smushed it with my foot.

CONS

The mother was complaining, accusing the hospital of giving her baby an infection. In a way, she was right. Her baby, a twin born at 31 weeks gestation, developed a coagulase negative staph (CONS) infection at the age of ten days. CONS are bacteria that live on our skin and other parts of the environment. They cause no harm to us, but to premature babies with poor immune systems they can cause a real infection. In fact, they are the most common cause of late onset infections in the NICU.

I have mixed feelings about CONS and blaming hospital workers for transmitting CONS infections. I don't just want to say, oh well, infections happen, because there are measures we can take to try to decrease the rate of such infections, like good hand washing, and I think we need to keep trying to improve in this area. On the other hand, even with our best efforts some babies get CONS infections. I don't think any hospital has totally eradicted it from their NICU. Also, it's possible that the mother or another visitor transmitted the CONS bacteria to the baby.

The mother kept complaining and said that she should transfer the baby to the hospital across town, where her aunt works and where "they know how to take care of babies." Finally, our nurse had had enough. She asked the mother where she received her prenatal care, knowing that mother had very limited prenatal care, and knowing that she had used marijuana during her pregnancy. When asked why she hadn't gone for more prenatal care, the mother sputtered a bit and said it was because she had planned to abort the babies, but when the father went to jail she decided to have them. (We couldn't figure out that reasoning either, but hey, whatever blows your hair back.)

We know that we're supposed to be nice to parents of NICU babies, even when they are critical of us. We know that hospitals should offer good customer service. We know that having your baby in an NICU can be stressful and make you say things you might not otherwise say. But if there is one thing we have trouble tolerating, when we're doing our best to optimize these kids' outcomes, it's taking crap from a mother who didn't even care enough about them to get decent prenatal care. After all, we're only human, too.

Fantasy

We've all got our fingers crossed about a baby who went home today. Born at 27 weeks gestation, she needed to be on oxygen for a long time but otherwise did very well. Her twin went home a few days ago. Our fingers are crossed because mom is not exactly a shining star. She's very nice but young (16) and a bit slow. She takes some, but not all, special ed classes. Teaching her things like the need to support the head of a baby when holding her, what a pediatrician is, and so on took extra effort. Her guardian is her grandmother who is wheelchair bound.

Social services checked out the situation. It's one of those deals where the family isn't bad enough to justify removing the children from the parent but is bad enough to make us, the doctors and nurses who cared for her, pretty worried.

In the next room in our NICU lies a baby who is very sick from an infection. I'm not sure if he will be alive tomorrow morning when I go to work. His parents are very nice and have visited him together every day since he was born six weeks ago. They seem like they would make great parents, and they'll be devastated if their baby dies.

It makes me wish that sometimes I could just switch the parents around. I mean, wouldn't it be better if the 16 year old mom, who is barely bright enough to manage routine child care, had the baby who died, and the other parents, so excited about their baby, had the twins who should do pretty well in a decent home? Don't take this to mean that I think dumb parents wouldn't feel the loss very hard if their baby died. I know they would; you don't have to be smart to love your kids. But it's just not fair. The sixteen year old, who needs a baby like she needs a hole in the head, has two, and we hope like crazy that they are resilient enough to take some subpar parenting, while the other parents might have none.

I guess we can't fix everything, and I should probably focus on keeping the six week old alive instead of fantasizing about switching parents.

Wondering

In some ways my job gets easier as I get older. Advances in neonatal medicine make it easier. I have more experience and there are fewer and fewer situations that I haven't handled before. Even if there is a new problem, I have handled enough other problems that I'm pretty confident about the new one. It's also easier to talk to parents when you have that confidence.

In some ways, though, my job gets harder as I age. Yesterday was a very busy day, and there was one particular baby who was very sick and took a lot of attention. There were nearly constant concerns about him: Does he need more fluids, different antibiotics, blood, platelets? It was true critical care medicine. I enjoyed it, but when I got home I was mentally exhausted, seemingly more so than I would have been earlier in my career, although maybe I just don't remember how tired I used to get.

I've never been one to think that doctors' jobs are more stressful than those of other people. Even though we deal with health and sickness, sometimes life and death, we're trained for it, and besides, there can be significant stress in other jobs. Many people have to finish projects or reports by deadlines, or are judged harshly if they don't do their job properly, have to deal with challenging people all day, or simply have to deal with mind numbing boredom day in and day out.

Lately, though, I've been wondering if maybe my job is on the more stressful end of the spectrum. This past weekend I visited my daughter's college, and while there we went to an office of a music professor. His office included two large CD storage towers, a stereo, a Mac computer, and - get this - a large pipe organ. (Is there no justice? I've been trying unsuccessfully for a couple years to get a new combination radiant warmer/incubator that costs $30,000, while this music prof has a pipe organ worth several hundred thousand dollars.) Anyway, I thought, what a nice job he must have, and how little stress there must be. He can listen to music all day, maybe make a few tests, and teach some music lessons. Sure, at one time he probably had to attain tenure, but is that so big a deal in a small college music department?

It's not only what he has to do for his job, but also what he doesn't have to do, namely, he doesn't have to worry about getting a sick baby's oxygen level up when you've already tried everything you can think of, or deal with parents angry because their baby can't go home. There are times when his life looks pretty good, and I can't help but wonder how I'd like it.

I'll never know.

Directive

The little girl had a tracheostomy as a complication of her prematurity, although her lungs were in pretty good shape. She was living with her dad, and mom is out of the picture - I'm not sure why. One day the dad stepped outside to have a cigarette. The baby, inside by herself, pulled the tracheostomy tube out and her airway closed off. By the time dad went back inside from his smoke the baby had been without air long enough to cause significant brain damage. Now the baby is hopitalized on a ventilator and in a vegetative state.

This is not, nor ever was, my patient, but is one of a pediatrician friend of mine. She told me about the case after she had just been to a team meeting of the baby's physicians and other caregivers with the father to decide what to do. The baby is stable and could go home on a ventilator, although the physicians think that given the baby's condition, removing the ventilator and letting the baby die is the most appropriate thing to do. Father is declining to do so.

After the meeting my pediatrician friend talked with the dad a little longer, one on one, and said to him, "You know, it's okay sometimes to just let the baby die," or words to that effect. She thought the dad understood the reasons for discontinuing life support but just couldn't bring himself to do it. (Of course it's tough for dad to give the okay to let his child die, not only because that's always tough to do with your child, but also because of the guilt he must feel for letting his baby pull out her tracheostomy tube.) Afterwards, though, my friend wondered if she had been too directive with the father.

I don't think she was too directive at all. Yes, we are taught to be non-judgemental about many tough decisions parents have to make, and we have to respect that, but we can't totally cop out of our responsibilities either. We physicians and nurses have seen these types of situations before; we've thought through the ethics of it and can bring some objectivity to the discussion. The unfortunate parents are almost always dealing with this situation for the first time, and, I think, need and appreciate some guidance.

I know we have to be careful with this and not be too directive (although who decides what too directive is?) Also, there are some fringe physicans and others who could abuse their influence with the parents to let some kids die who shouldn't, and vice versa, but for the most part we have something to offer to parents and would give appropriate advice. Parents are in a terrible situation when these things occur. We shouldn't force them to see things our way, but at the least we can help them think through it, and personally I think we can give them a nudge in the right direction. It's our job to help them and not just back off and stay away from the tough decisions.

P.S. Check out a new Pediatric Grand Rounds at Tales from the Womb.

Scrutiny

The baby had been sick before she was born. At 29 weeks gestation mom came to the OB clinic with the baby poorly grown inside her. The baby wasn't moving much, and the baby's heart rate never varied, an often ominous sign. The heart was big and there was fluid in the abdomen. After they delivered the baby that night she continued to be sick and gave us a real workout. She was on a conventional ventilator, then the oscillator ventilator, then a conventional one again, and finally after four days was stable and needing only a moderate amount of help from the ventilator. She still had a ways to go, but was looking like a more typical premature baby who just needs to grow and mature for awhile.

It was a surprise, then, when I came in the next morning and heard my partner tell me the baby had died the night before. Nobody was sure why. The nurses had been changing the IV fluids and tubing attached to her umbilical lines when the baby coded and could not be revived.

Deaths in the NICU can be roughly sorted into a few categories. The most common kind of death is the extremely premature baby, the immature 23 weeker whose lungs and other organs are just not mature enough to make it. Simply born too early, these kids usually die within a couple hours to a couple of days after birth. Another category would be those babies with terrible chronic lung disease who survive several months but are never good enough to go home and who finally die. These don't occur often nowadays but are always hard when they do because everyone has grown attached to the baby. Some kids will die from infection, although with Group B strep treatment of the mom in labor and liberal use of antibiotics in newborns these deaths are becoming less frequent as well.

The deaths, though, that drive me crazy are the ones like in this baby, a child who is doing well when something unexpected and unexplained happens. This seems like the type of death that is the most preventable and deserves close scrutiny. As soon as I have time and the chart is available, I'll go over it closely to see if I can find any clues to the reasons for this death. I'll talk to my partner who was on duty at the time, and maybe to the nurse. I'm not trying to blame anyone; I just want to see if there is something we can learn from this, something we can prevent from recurring.

When bad things happen in the NICU, you can take one of two attitudes. You can say "Oh well, some tiny babies are bound to die," or you can try to examine the case and look for information that might give you even a tiny advantage in dealing with the next baby. I like to choose the latter approach. Paying attention to small details can help small babies survive, and that, after all, is what we do for a living.

Moustache

Her baby isn't very sick and will be in the NICU only a few more days. When mother comes to visit she is polite, nice and neat, and appropriately dressed. Her eleven year old daughter, often wearing her school uniform, usually comes with her. I really like the mother, but there's just one thing about her that bugs me: she has a moustache.

I don't mean just a little darkening of her upper lip, like many women have. She has a nearly full set of bristles, a moustache that many a teenage boy would be proud to have. There's no missing it; it's really quite manly.

I don't get it. This otherwise very nice and seemingly normal woman goes around with a moustache. It's hard to believe that she doesn't notice it, because it's hard to miss. She's not the only mom I've seen like this, either. Periodically we have mothers who have a lot of facial hair. I remember one who had a very nice goatee. That is, it would have been nice if it were on a man.

I don't mean to sound insensitive here. I'm sure that facial hair is a vexing problem for many women. Also, I'm sure that many of the mothers I deal with don't have a lot of money to spend on expensive facial hair remedies, such as laser treatment or electrolysis or even hair stripping by a beautician. But still - shaving and putting a little makeup on to hide the stubble or using a dipilatory can't be very expensive. Why don't some women do that?

I realize that this is not the most serious issue we deal with in the NICU, but it is one of the most puzzling. There's an old Happy Days episode (I'm really dating myself here) where Fonzie is expounding on desirable attributes in a woman. When he says "no moustache," Richie and the boys all nod and murmur assent. I think that's a pretty universal opinion.