Week Three

All babies spit up.  He is making wet diapers.  He is gaining weight.  He seems fairly happy and content.  These are some of the various statements I kept repeating to myself and to Katie as we progressed through our third week at home in an effort to make ourselves feel better.  As previously mentioned, Edward had started to spit up somewhat frequently and it seemed to be getting worse instead of better.  Still, the above statements were true.  He was gaining weight consistently and continued to make wet diapers - essentially the two goals of feeding.   But it seemed like we were fighting tooth and nail to get every milliliter of breast milk in him and to keep it in.

Reflux is a common problem in babies and especially in premature babies.  For reasons that are unknown (at least to me), the lower esophageal sphincter (LES) tends to intermittently relax allowing gastric contents to reflux retrograde back into the esophagus.  In other words, the feeding tube leading to the stomach (the esophagus) is separated from the stomach by ring of muscle that acts like a valve (the lower esophageal sphincter).  When you swallow, that valve opens up allowing food content to pass into the stomach.  That valve then closes and what you eat spends some time in the stomach being digested and churned about.  Then, another muscular valve at the end of the stomach (the pyloric sphincter) acts as the exit valve that allows food content to pass into the intestines.  Reflux occurs when the first valve between the stomach and esophagus inappropriately opens up.  In adults, reflux is typically caused (or at least made worse) by acid over-secretion -  which is why antacids and acid reducers are the mainstay of treatment for heartburn.  In newborns, acid over-secretion can be a contributing cause for sure, but the issue is generally more mechanical due to the floppiness of the muscular valve.  Regardless of its cause, reflux in a newborn can wreak havoc on their feeding and subsequently on their growth and development.  It can also wreak havoc on the parents as each feed seems like an interminable battle that is painful for both parties involved.  Edward seemed to be getting progressively fussier and fussier by the day.  We were afraid that we were doomed to a long struggle with reflux.

We kept the faith though, pressing on with bottle after bottle.  Then things changed.  The night before we had two follow-up appointments, one with our pediatric general surgeon who did the bilateral hernia repair in the hospital and the other with our regular pediatrician, Edward took a great bottle of nearly two ounces!  Maybe we were starting to turn a corner!....but alas, he spit up again.  But this was a little different.  It came out forcefully and had some pretty good distance to it.  Then he did it again later than night.  Hmmm......

Our first appointment was with the pediatric surgeon.  I was not able to join Katie and Edward for this appointment, but as Katie was describing Edward's symptoms, the surgeon mentioned the possibility of pyloric stenosis.  As mentioned above, the pylorus is the exit valve of the stomach, a muscular ring that can contract and relax as needed.  Pyloric stenosis is abnormal hypertrophy (enlargement) of that muscle which then does not allow food to pass into the intestines and causes back up into the stomach.  Pyloric stenosis is classically associated with two things:  projectile vomiting and an olive-sized mass in the epigastrium (just above the belly button).  Edward was starting to projectile vomit, but only intermittently; furthermore, many of his symptoms seemed like reflux.  The surgeon carefully examined Edward's abdomen for the "olive" but it was nowhere to be found.  The surgeon asked Katie if Edward had thrown up anything green or brown.  Nope.  It was all milk so far....though some pretty malodorous stuff - even his burps smelled particularly foul.  Well, the surgeon said, this could be pyloric stenosis but it is not definitive - let me know if it gets worse!

I left work early that day to join Katie for the pediatrician appointment scheduled for that afternoon.  We fed Edward one more bottle before the appointment right around noon.  Sure enough he spit up again, but this was no ordinary spit up.  This hit Katie's chest with such force that it caused back splatter onto Edward.  Furthermore, it was brown....like coffee grounds.  In the adult world, coffee ground emesis is another classical description and typically portends something fairly serious.  Vomit becomes coffee ground in quality in presence of upper gastrointestinal bleeding which allows blood to be exposed to gastric acid, leading to the oxidization of iron molecules found within the blood cells.  In Edward's case, he was likely bleeding for one of two reasons:  either he had gastritis which is irritation of the lining of the stomach or he had something called a Mallory-Weiss tear, which is a small mechanical tear in the mucosal lining at the junction of the esophagus and stomach secondary to repeated vomiting

To put it lightly, Katie was beside herself and I was pretty concerned myself.  We considered going straight to the ER, but since our doctor's appointment was in 15 minutes we decided to start with that.  Our pediatrician was also quite concerned, but again he could not feel any evidence of pyloric stenosis on exam.  Furthermore, there were many other potential causes of Edward's symptoms, some serious and some not so serious.  So, he called the surgeon who we saw that morning and they decided to send us to the main hospital for an ultrasound that afternoon.

Katie dropped me off and I took Edward to Radiology while she ran home to get some essentials in case we were in the hospital all afternoon or evening figuring all this out.  I sat in the Radiology waiting room with Edward in my arms - he was getting pretty lethargic from all the vomiting and lack of nutrition.  And even though we had not fed him anything for a few hours, he spit up again all over me.  Dark brown stuff - the poor little man! His eyes had this glazed over look and he seemed so worn out.  "He spent 3 long months in the NICU only to come home to this!" I thought to myself.  I have to admit that was one of the lowest points for me throughout all this whole process.  Finally, soon after Katie arrived, they called us back into Ultrasound.  While we were waiting, I confessed to Katie that I was actually hoping for pyloric stenosis.  There were other possibilities that were more serious (intussusception or volvulus) or less treatable (such as reflux) and I was worried the ultrasound would be totally normal.  Then we would be left with this poor baby who seemed miserable, vomiting all the time and two parents who were equally miserable and close to wits end. 

Then finally, we got the results:  Pyloric Stenosis!  As strange and as counterintuitive as it seems, I was overjoyed!  We had a diagnosis! .........So now what?