The message on the pager caught my attention just as I was about to leave for my Sunday morning rounds at the hospital. I was on call for all the pediatricians in town this weekend and had a busy morning ahead of me. I called right away. A message like that could be anything from a stuffy nose to a severe respiratory problem.
“Hello, this is Dr. Cohen. What’s going on with your baby?”
“I don’t know. He seems to be breathing funny.” She didn’t sound panicked.
“Is he having trouble breathing? Is he turning blue?”
“No, it’s just that he’s making a kind of funny noise when he breathes, almost like he’s gasping or something.”
“Is he doing it right now?”
“Well, no, it seems to come and go. He’s been doing it since early this morning.”
After a few more questions, I decided that she didn’t need to call the ambulance, but I did need to see the baby as quickly as possible. I told her to bring him to the emergency room and ask to have me paged.
As I drove to the hospital, I thought about what might be troubling this infant. He might have pneumonia, or he could be wheezing from asthma or bronchiolitis, an inflammation of the lower airway. Choking on a foreign object could also obstruct the airway. Or maybe he had some systemic illness that was affecting his breathing: congestive heart failure, for example, or overwhelming sepsis. I needed to see him to sort this out.
I was treating a sick baby in the nursery when Matthew arrived. The nurse advised me that the boy appeared to be in distress, so I asked the emergency room doctor to see him first. By the time I got a chance to see him, Matthew had just had his chest X-ray taken. I glanced over and saw a pink and alert 1-year-old who appeared to be breathing normally. I turned my attention to the X-ray, which was completely normal.
“Hi, Mark.” Sarah Costello, the emergency room doctor, joined me. “I went over the boy pretty thoroughly, and I really can’t find anything. The parents say he’s been having this funny breathing intermittently—they say he did it over in X-ray—but I haven’t seen anything unusual. He looks great to me.”
I thanked Sarah and went into the examination room. The parents were in their thirties, and Matthew was their first baby. Joan had been an accountant before her pregnancy, and her husband worked for the county government. They looked concerned, but not panicky. Joan was holding Matthew, who had fallen asleep. I did a thorough exam and, like Sarah, found nothing unusual. “Dr. Costello tells me he started doing this in the X-ray department,” I said.
“That’s right,” Joan replied. “But the strange breathing happened when he was lying down. After the X-ray, when they sat him up again, he stopped doing it.”
I perked up. “And you said it was like he was gasping?”
“Yes,” she said, “like this,” and she demonstrated a kind of quick panting or gasping pattern of breathing.
Symptoms when he was supine but not when he was upright. I suddenly wondered if Matthew was having gastroesophageal reflux. In this syndrome, the gasping could be a manifestation of pain—not necessarily respiratory problems. Although the condition is not typical in 1-year-olds, the diagnosis seemed to make sense.
Gastroesophageal reflux occurs when the esophagus fails to function properly. In healthy people, the lower end of the esophagus normally stays closed, preventing acidic fluid in the stomach from backing up into the esophagus each time the stomach contracts. This part of the esophagus, which is called the lower esophageal sphincter, is not a distinct muscular valve but rather an area of relatively higher pressure. The higher pressure keeps the esophagus closed off from the stomach and helps prevent acid and food from traveling back up the esophagus.
When adults have acid reflux, they feel heartburn, a burning pain in the mid to upper chest caused by acidic stomach contents irritating the unprotected lining of the esophagus. Cigarettes, caffeine, and certain foods like chocolate, tomatoes, and peppermint can exacerbate such symptoms, either by decreasing the lower esophageal pressure or by irritating the esophagus. Obesity and pregnancy are common predisposing factors. So is position: Many patients find that lying on their backs brings on their symptoms. Elevating the head of the bed on blocks may be helpful. In addition to diet modification, weight loss, and positioning, antacids can provide relief for many of the 15 million or more Americans who experience daily symptoms of gastroesophageal reflux.
Acid reflux among infants has other causes. The condition is common, for example, in preemies and babies with neurological disorders. It also occurs in more than 50 percent of normal babies under 6 months of age because the esophageal muscle is not yet developed enough to produce the high-pressure zone. Usually these babies just spit up frequently, and the problem resolves itself with time or with simple measures such as keeping them upright after feeding. Occasionally, however, reflux in infants can cause more severe problems, such as poor growth or lung disease from breathing in food.
Matthew had not had any of these problems in early infancy. So why would he suddenly begin developing them? I noticed that Joan was nursing, and I asked her if she’d been taking any medications or had eaten any new or unusual foods.
“Well, I’m pregnant again, and I’ve been taking this herbal tea for morning sickness.” The tea contained raspberry leaf and chamomile, she said. As far as I knew, neither of those would cause reflux, but I told her I’d look it up in my reference guide to alternative treatments if she could get me the name of the product.
“Wait,” she said. “I just remembered: Yesterday I was at the convenience store, and I was so thirsty I had a large root beer.” Aha! I felt like a detective who’d just cracked the case. I happened to know that the root beer sold at that chain of convenience stores, unlike most brands of root beer, contained caffeine—and caffeine is known to decrease lower esophageal pressure.
When I explained this, Matthew’s parents said it made sense because Joan was usually careful to avoid caffeinated beverages. The root beer was the first drink she’d had with caffeine since becoming pregnant with Matthew. I told them to call me immediately if his symptoms got worse, and that if his symptoms did not disappear in a day or two, they should check with their regular pediatrician.
Matthew’s father looked at me with a wry smile. “So you’re telling us that we rushed our baby to the emergency room because of heartburn?”
“Don’t feel bad about it,” I replied. “Ask the ER doctor how many people are rushed here for chest pain that turns out to be heartburn.”
About a week later, my receptionist said: “Dr. Cohen, a woman dropped off a package for you. She didn’t leave her name.” There on my desk was a brown paper bag with a note thanking me for my help with Matthew. His symptoms had vanished by the next day. The bag also contained a six-pack of root beer. Uncaffeinated.
Mark Cohen is a pediatrician in Honolulu, Hawaii. The cases described in Vital Signs are true stories, but the authors have changed some details about the patients to protect their privacy.