IDENTIFYING THE CAUSE OF IRRITATION IN A CEASELESSLY CRYING BABY

What do you do to console a three month old baby who has been crying tirelessly for about one week? Her mother reported that even breastfeeding was not able to console the child, who cried intermittently even while breastfeeding. By this time, her mother had joined in crying also, and we had both mother and child crying at presentation at the consulting clinic. Who do you console first, and what do you do to gain the trust of the wailing mother that her dear baby girl was not in any grave danger. Keywords: Crying baby, wailing mother, cause of crying. Corresponding Author: Dr. E. B. Anyanwu. Department of Family Medicine, Delta State University Teaching Hospital, Oghara. P.O. Box 7, Oghara, Delta State Nigeria. E-mail: ebirian[@]yahoo.com Tel: +2348035701711 Case Presentation A young mother brought in her three month old baby girl with the history that the baby has been crying excessively for about one week without any known reasons. There was no history of fall given by her mother. No history of fever, no diarrhea and no convulsion reported. The child has been passing urine normally and apparently she had a soul appetite. Her mother reported that she has noticed that the baby has been pulling on her ears repeatedly. There was neither ear discharge noted nor any offensive odour from her ears. She was said to have vomited once. She was up-to-date with her immunization schedule. The baby had not responded to all the consolation offered by her mother. Not even the act of breastfeeding, an act the baby enjoyed before the present state, stopped the excessive crying. Even while breastfeeding the baby cries intermittently. Her sleep at night had also been disturbed. Soon after, her mother also started crying not knowing what next to do to stop her baby from crying too much. Intermittently during the office consultation, the baby will start to cry and her mother joins in, thereby breaking the sequence of the interview. Examination revealed a non-febrile, healthy looking baby girl, who was not pale, well hydrated and not jaundiced nor cyanosed. She was however very irritable, crying even without any stimulus. The systemic examination was essentially normal. The anterior fontanel was normotensive, neck was supple. She moves all four limbs well though irrationally. The ear examination revealed inflamed, reddish tympanic membrane of both ears. There was no discharge, and no ear wax noted. A working diagnosis of an irritable child ?secondary to bilateral otitis media was made and admission was offered to her mother, who readily agreed for the admission. Laboratory investigations were ordered and results were as follows: White blood cells = 11,000/mm3 (4,800 – 11,000) Neutrophile = 57% Lymphocyte = 43% Haemetocrite = 28% Malaria Parasite = Nil Random blood sugar = 112mg% Cerebro-spinal fluid analysis = normal Intravenous injection of an appropriate antibiotic was started for the child and gradually over a period of three days, the girl improved and the irritability decreased dramatically. She was discharged home on the third day of admission no longer crying and her mother happy. Discussion An inconsolably crying child presents a diagnostic dilemma, in as much as the baby cannot communicate with you. The issues at hand are even made worse if the pressure has been transmitted to the parents of the baby, who should have been more alert and sensitive to the baby’s situation. This usually leaves the clinician with virtually nothing to start with and then the needs to start a comprehensive search for the possible causes of the presenting baby’s illness. The presenting baby was reported to have started crying inconsolably over a period of about one week. No fever was reported. Baby was still very active and her mother felt initially that the baby was not getting enough “food” from the breast milk since the baby was being exclusively breastfed. She then resorted to breastfeeding the baby more frequently, but this did not help matters as the child continued to cry as much as before. The mother who was greatly alarmed by this time felt that maybe her breast milk had gone “sour” and that the baby was rejecting both herself and the “soured” breast milk. It was at this point that she broke down and started crying alongside the crying baby. She was completely devastated by her baby that her breast milk has gone sour. Unfortunately, she had some elderly women in her community who agreed with her that the ‘soured’ breast milk was responsible for the baby crying so much and for so long. The introduction of complementary feeding did not help matter as the baby vomited the initial feeding and was still irritable. The grandmothers around her then suggested that the problem was “abnormal colic” and gripewater first and nospamin latter were introduced, again to no avail. The mother’s state now was that of total confusion. Irritability in a child was most commonly attributed to cerebro – spinal infections but many other conditions can cause it. Such other conditions include hypoglycemia, simple and complicated malaria, otitis media, urinary tract infection and pulmonary infection. A thorough systemic examination only showed features of bilateral otitis media. A lumbar puncture for cerebro-spinal fluid analysis was essentially normal, thereby ruling out any central nervous system infection. Malaria parasite smear that was done was negative for malaria parasite. It is known that malaria fever caused by plasmodium falciparum can cause severe and complicated malaria (1) which can present with irritability. The young girl however did not have any history of convulsion, neither was she obtunded. She was fully conscious and there was no change in her sensorium. Malaria fever can also cause hypoglycaemia, (2 – 4) which can also present with irritability and changes in sensorium. There may be episodes of convulsions and if not properly treated, patients may lapse into coma. Otitis media is a known cause of irritability in children, and the baby’s mother reported that the baby was noted to have been pulling on her ears. But in the absence of signs and symptoms, ear tugging alone is a poor indicator of acute otitis media (5,6). The commonest bacterial agents previously isolated from middle ear fluid cultures are Streptococcus pneumoniae (43%), Moraxella catarrhalis (21%), Haemophilus influenza (18%) and Respiratory syncytial virus (7%) and Rhinovirus (3%) (6). The most dangerous immediate complications of acute otitis media involve local suppurative spread to structures within the temporal bone and beyond into other compartments of the cranial vault, causing such conditions as mastoiditis, labyrinthitis, facial nerve paralysis, osteomylitis, meningitis and brain abscess. Others include perforation of the tympanic membrane, chronic otitis media and hearing loss. There is evidence that repeated bouts of otitis media may have adverse effects on speech development and language acquisition. Since the availability of antimicrobial therapy, the incidence of intracranial complications has decreased. In the pre-antibiotic era, three percent of cases of otitis media were associated with intracranial complications such as mastoiditis and lateral sinus thrombosis (5). An irritable baby needs a calm, proper and appropriate work-up to discover the cause of irritability. It is not enough to reassure the mother. Every effort must be made to be certain that there are no medico-surgical reason for the present illness. References 1. Warrel, D. A., Molyneux M. E., and Beales, P.F. (eds). World Health Organisation Division of Control of Tropical disease. Severe and Complicated Malaria. 2nd edition. Trans Roy Soc Trop Med Hyg 1990; 84 (supplement 2): 1 – 65. 2. Kochar, D. K., Thanvi, I., Kumawat, B.L., Shubhakaran, and Agarwal, N. Importance of blood glucose level at the time of admission in severe and complicated malaria. J Assoc Physicians India 1998 46(11): 923 – 925. 3. Migasena, S. Hypoglycaemia in falciparum malaria. Ann Trop Med Parasitol 1983; 77 (3): 323 – 324 4. Wurie, A.T., Wurie, I. M., Gevao, S.M., and Barrie, A. U. The effect of malaria on some laboratory parameters in Sierra Leoneon Children. Nig Qtr Hosp Med J 1998; 9(1): 1 – 3. 5. Kline, M.W. Otitis media. In: Oski’s Pediatrics Principle and Practice. 3rd Edition. McMillan, J.A., DeAngelis, C.D., Feigin, R.D, and Warshaw, J.B., (eds). 1999. Lippincott Williams and Wilkins Philadelphia 1301 – 1305. 6. Polin, R. A., and Ditmar, M.F Otitis media. In: Pediatric Secrets 2nd edition. Hanley and Babfus, Inc Medical Publishers Philadelphia. 1997: 295 – 298.

Treating the healthcare crisis by increasing medical school enrollment

AUTHOR: Adam E. M. Eltorai

Caring for the sick is not only a responsibility that we share as people of one nation but a moral issue. The millions of Americans who are uninsured, under-insured, or who have to declare bankruptcy due to medical expenses are a growing reminder of the distorted healthcare system that has evolved in our country. The ever-rising costs of insurance, the mounting healthcare costs burdening employers, the denial of coverage for pre-existing conditions, as well as the lack or portability of existing coverage are all due to the “money-driven” political influence of the health insurance industry, for-profit hospitals, and the pharmaceutical industry. After decades of discussion in Washington, insufficient healthcare reform legislative changes have occurred. Without fundamental reform, the collective health of the American public suffers.

The healthcare crisis is exacerbated by an increasingly severe primary care physician and nursing shortages. Even if more individuals are covered by insurance, there will be too few physicians to provide the necessary primary care. Insuring more patients but not increasing the number of physicians will result in higher service demands and longer patient waiting periods.

Looking at the grossest measure of national health, life expectancy, people in Switzerland, South Korea, Iceland, Belgium, Greece, Italy, France, Germany, Spain, Sweden, Finland, Netherlands, and Ireland are living longer than us because they have more practicing physicians per capita.

Today, 30 million people live in areas deemed to have too few physicians, according to the American Association of Medical Colleges (AAMC). The U.S. only trains about 27,000 new doctors per year. Consequently, the AAMC says that by 2025, the U.S. will be facing a shortage of as many as 150,000 physicians.

A particularly worrisome trend is the shortage of primary care physicians. The U.S. is already in need of an additional 16,000 primary care physicians, according to the U.S. Department of Health and Human Services. This need of additional primary care physicians is expected to grow to 45,000 by 2020, according to the AAMC. However, fewer medical school graduates are entering primary care. Between 2002 and 2007, there was a 25% decrease in the number of medical school graduates opting for careers in family medicine. As the healthcare gatekeepers, too few primary care doctors may result in increased patient waiting periods and altogether decreased healthcare access. Compared to other developed nations, the percentage of primary care physicians in the U.S. is significantly lower.

The physician shortage is even more troublesome given America’s changing demographics. The American Medical Association (AMA) noted that the U.S. population grew by 31% from 1980 to 2003. In addition to growing in number, the U.S. population is aging. The baby-boomer generation is approaching an age of increased health demands. Older individuals are more likely to have more chronic and complex ailments, requiring more involved treatment, operations, and hospital visits. By 2025, the number of people older than 65 is expected to increase by approximately 75%—37 to 64 million.

As the population ages, so do the physicians. The AMA says that two-thirds of all practicing physicians (about 800,000 today) are of the baby-boomer generation or older. The remaining one-third of practicing physicians, ages 27 to 41, possess different work habits. The younger generation of physicians increasingly prioritizes quality of life. Some of these physicians work less and are not as willing to see as many patients at the expense of their personal lives.

A direct approach to drive down the cost of healthcare, to decrease appointment waiting times, and to increase the opportunities for access to healthcare, is to increase the number of practicing physicians. More physicians would mean more competition. More competition would mean lower costs of care. Lower costs would enable more people to pay for healthcare. Poorer Americans would be more inclined to visit the doctor when their health problems are preventable or treatable, rather than waiting until the last, most expensive moment to visit the emergency room.

In the U.S., there is an obvious bottleneck when it comes to producing physicians: medical school enrollment. In 1980, the AAMC expected there to be a surplus of physicians, so a policy of capping medical school enrollment was enacted. Since then, the need for physicians has surpassed the number of physicians being admitted to medical school.

Unlike entrenched special interest groups (i.e. pharmaceutical or healthcare insurance industries) which have profound financial clout over members of congress, medical schools are relatively autonomous and therefore can offer a potential avenue for effective change.

Although some medical schools are catching on to the idea of increasing enrollment, the increased class sizes have not been large enough. Over 40 thousand students apply to medical school every year and less than half are offered admission. According to the AAMC, in fall 2009, only 18,000 students entered U.S. medical schools. Most medical schools have class sizes of less than 200 students. Many medical schools consist of classes of less than 100 students. Several schools have only 40 students per class.

Why are class sizes so small? Smaller class sizes mean that acceptance rates are lower (in some cases, less than 3%). Lower acceptance rates mean the school appears to be more selective. Being perceived as a highly selective institution is good for business. Selectivity can easily be mistaken for quality of patient care.

These incredibly low acceptance rates results in a peculiar and worrisome sociological side effect. Such medical school admissions selectivity produces applicants who become blinded by their desire to actually gain admission that they lose sight of the purpose of medicine: to help those in need. The medical school admissions process is becoming so focused on relatively arbitrary “measures of quality” (i.e. high GPA and MCAT scores) that they are losing sight of essential qualities of good healers. I am concerned that the medical school admissions process is selecting for increasingly neurotic nerds, who may lack the essential human qualities of empathy and compassion of great physicians.

The U.S. has the capacity to train more physicians. Each year, residency spots go unfilled. American residency programs can and should train more U.S. medical school graduates. According to the AMA, nearly 40 percent of the medical students entering U.S. residency programs were foreign medical school graduates. Many of these foreign medical school graduates return to their home countries after being trained in the U.S., thus not helping with the physician shortage in the U.S. Increasing U.S. medical school enrollment and therefore resident physicians who are more likely to practice in the U.S. may help alleviate the physician shortage.

To further increase the total number of practicing physicians, the number residency training slots should also be increased. Residency programs are funded by Medicare. This funding accounts for less than 1% of all Medicare expenses. Increased residency slots can be achieved by increasing this funding.

Although a worthy long-term goal, increasing the total number of residency training slots in the U.S. will have to overcome significant financial and bureaucratic obstacles. In the mean time, increasing the number of U.S. medical school graduates entering U.S. residency programs may provide a more immediate solution.

Furthermore, I propose that increasing medical school enrollment will have another particularly important consequence. Larger medical school class sizes will allow medical schools to lower their tuition costs per individual. Lower tuition will result in decreased medical student debt. Some medical schools’ tuitions are $50,000 per year for four years. Many physicians begin practicing with several hundred thousands of dollars debt. Consequently, students are more inclined to choose higher paying, procedural-based specialties. In other words, medical school graduates cannot afford to go into lower-paying primary care positions. Smaller debt burdens from decreased tuition rates would allow more medical school graduates to enter primary care.

With more primary care practitioners, the national focus can shift more towards prevention rather than more costly treatments. More primary care physicians will reduce the need for more expensive emergency room visits.

Simply increasing medical school enrollment with well qualified students promises to have a significant effect on the number of practicing physicians, improved access to primary care, lower cost of health care, and therefore the health of the nation.

About the Author: Adam E.M. Eltorai is the author of the book "The Pre-Med Bible"