you have the charts with you, by any chance?’ Natalie asked.
‘Oh, yes. I’ve got her red book.’ Ella dug in her handbag and eventually brought out a slightly dog-eared book with a C written neatly on the front. Natalie flicked to the charts. At birth, Charlene’s weight had been a little below average, on the fortieth centile: meaning that sixty per cent of babies at the same age would be heavier than she was. By three months, Charlene had dropped to the tenth centile, from six to twelve months her weight was on the third centile, and the measurement the paediatric nurse had done a few minutes before showed she’d dropped below even that. Charlene’s height, too, was below average, on the twenty-fifth centile. But Ella had clearly taken care to have her daughter’s height and weight measured regularly, and as Natalie flicked through the book she noticed that all the immunisations were up to date.
‘She’s a bit of a tomboy,’ Ella said apologetically as Charlene stopped fidgeting, wriggled off her lap and headed straight for the toybox, emptying the entire contents out. ‘I’ve stopped trying to keep her clean all day. She starts out with fresh clothes, but if I changed her every time she gets grubby…well. I’d never have the washing machine off. So I just put her in the bath every night and give her a good wash.’ She bit her lip. ‘I was wondering if she had—’ her voice lowered in obvious embarrassment ‘—worms, or something. If that’s why she’s skinny. Can you do an X-ray or something to check?’
‘An X-ray’s probably not going to be very helpful right now,’ Natalie said gently, ‘and we don’t want to expose Charlene to radiation if we don’t really have to. As for the other problem—’ she’d picked up on how awkward Ella clearly felt ‘—you’d be surprised at just how common it is. Kids pick them up really easily. Does she talk about itching at all? Or do you see her scratching her bottom?’
‘Well, no,’ Ella admitted.
‘It’s unlikely to be worms, then,’ Natalie reassured her. ‘Though if you really want to be sure, when she’s asleep tonight, take a torch and shine it on her bottom. If you see anything white and wriggling, you’ll need to nip into the chemist and get some worming treatment—and do the whole family, not just Charlene. You’ll also need to keep her nails really short and get a soft nailbrush to keep them clean. What happens with worms is that a child scratches their bottom and some tiny eggs—so small you can’t see them—can end up beneath their nails. Kids that age normally have their hands in their mouth half the time so the eggs come out again, and the whole cycle starts again. It’s not anything you’ve done, so don’t worry.’ She paused. ‘Does Charlene eat anything odd?’ She was pretty sure the problem was chronic iron deficiency, and pica—eating abnormal things that weren’t food, such as coal—often went with it.
Ella shook her head. ‘I try and keep her off chips but sometimes it’s just easier to give in. At least then I know she’s eaten something.’
‘What about the toilet? Is she dry at night?’
‘Been out of nappies for ages. Just as well—Jayden isn’t, and I don’t think I could cope with three of them in nappies,’ Ella admitted.
Natalie smiled at her. ‘That’d be quite a tough call. Tell me, is anyone else in the family very light, or quite short?’
Ella shrugged. ‘We’re all pretty average, really.’
Not a genetic thing, then. The next thing to rule out was the possibility of a developmental disorder. She doubted it, because she’d heard for herself that Charlene’s speech was clear and her words were average for a three-year-old. ‘Is there anything you’ve noticed about the way she behaves, or the way she speaks?’
Ella shook her head. ‘She’s just a bit lively and a bit of a tomboy.’ She frowned. ‘You don’t think she has that thing where she’ll have to go on Ritalin, do you?’
‘ADHD? No,’ Natalie said, shaking her head. ‘I think it’s all to do with her being a fussy eater. It means she isn’t getting a balanced diet, and her iron stores are too low.’ Plus she’d been weaned too early. ‘She’s probably anaemic and iron deficient. It’s not serious,’ she reassured Ella, ‘and I can give you some iron supplements to help that. She’ll need to take them for about three months. But I’ll also refer you to a dietician, so she can help you with a few coping strategies to persuade Charlene to eat some meat and a few more vegetables.’
‘I do try,’ Ella said.
‘Of course you do. But sometimes you can do with a helping hand,’ Natalie said. ‘Being a parent’s one of the hardest jobs on earth.’ Though not being a parent could sometimes be even harder. She shook herself. ‘I’d like to take a blood sample and a wee sample, so I can check the chemicals in Charlene’s blood and that her kidneys and liver are working as they should be. I’ll give you a follow-up appointment for a fortnight’s time so I can check her weight and height and how she’s responding to treatment.’ She paused. ‘When are you due?’
‘In a month, though Jayden was three weeks early and this one might be the same.’
‘Maybe Charlene’s dad can bring her in?’ Natalie suggested.
‘He’s busy at work,’ Ella said swiftly. ‘And he never remembers appointments anyway.’
Unsupportive husband. Oh, Natalie knew all about that.
The sympathy must have shown on her face, because Ella added, ‘But I’ll try.’ With the same defensive note Natalie remembered in her own voice when she’d been the one making excuses.
Natalie took the blood sample—following it up immediately with one of Kit’s stickers—and talked Ella through taking the urine sample, then directed her to the reception area to book the next appointment.
‘What are you going to order?’ Kit asked as Natalie labelled the sample.
‘Full blood count, differential, electrolytes, calcium, phosphate, magnesium, iron, ferritin, folate, albumin and total protein, plus renal and liver function.’
He smiled. ‘Perfect.’
‘I didn’t miss anything, then?’
He spread his hands. ‘Maybe the involvement of Social Services?’
Natalie stared at him. ‘You must be joking. You don’t seriously think this is abuse by neglect, do you?’
‘Convince me,’ Kit said, his voice and face completely neutral so she couldn’t even guess what he was thinking.
‘In a month’s time, Ella Byford will have a newborn, a toddler and an under-four. Her partner clearly doesn’t pull his weight with the kids and she’s making excuses for him—sure, she’s having trouble coping right now and she needs a bit of support, but it’s definitely not neglect. Firstly, she’s the one who went to her GP because she was worried—it wasn’t the health visitor or GP prompting the appointment. Secondly, Charlene’s vaccinations are all up to date—which they wouldn’t be if she was being neglected. And, thirdly, Ella’s been meticulous about recording weight measurements. It’s not just the health visitor or GP’s measurements on the chart—some of the entries had Ella’s initials against them. This isn’t a mum who’s neglecting her kids, it’s a mum who’s having a rough time and needs support she isn’t getting from her partner.’
The words echoed between them and she couldn’t meet
