she just didn’t get to play outside very much, or her mum was rigorous with a high protection factor suncream. Or maybe it was anaemic pallor. Natalie needed to check for icterus—or a yellowish colour—too. Starting with the child’s fingernails, palms, mucous membranes of the mouth and the conjunctiva. The conjunctiva would be the tricky part—children hated having their eyes fussed with.
‘Can you open your mouth for me and say “a-ah”?’ she asked.
A-ah.’ It lasted all of half a second, but it was enough to show Natalie that there was slight pallor in Charlene’s mouth but no icterus. It didn’t look as if there were any ulcers, but if Natalie saw any other sinister signs in the rest of the examination she’d try for a second look.
‘And can I look at your hands now?’
Charlene scowled at her and tried to climb back on her mother’s lap.
‘Charlene, be nice for the doctor,’ Ella admonished her.
‘It’s not fair. I want to sit on your lap. He always does.’ Charlene shoved at her brother, who promptly fell off Ella’s lap and started howling.
Kit stepped in smoothly. ‘Hey. How about I read you a story, Jayden, while the doctor talks to your mum and your sister?’ He took two shiny stickers from his pocket. ‘And if you can both sit really still while the doctor’s talking— and while the doctor’s looking at you, Charlene—you can both have a special sticker.’
Why hadn’t she thought of that? Natalie wondered. And as a distraction technique it clearly worked, because Charlene immediately nodded, climbed onto her mother’s lap and sat still, while Jayden plonked himself on Kit’s lap so he could see the pictures in the story book. Ella, who’d looked close to tears, suddenly relaxed.
Teamwork. Good teamwork. And Natalie wasn’t going to let herself think about the fact that Kit was reading a story to a little boy.
‘OK, Charlene. Shall we see if your hands are bigger than mine?’
‘Don’t be silly. They’ll be smaller.’
‘Bet they’re not,’ Natalie said, putting her own hands behind her back.
Charlene giggled. ‘They are.’
‘Show me, then.’
To Natalie’s relief, when she brought her hands round again, Charlene splayed her palms and pressed them against Natalie’s.
‘Side by side now. Palm up,’ Natalie said.
The little girl, clearly thinking it was a game, did as she asked. Her palms were definitely pale, though at least there was no sign of yellowness.
‘And the back, to see if you have princess nails?’
‘You haven’t got princess nails. They’re not glittery,’ Charlene said.
Natalie was glad that Charlene’s weren’t either: it gave her the chance to notice that the little girl’s fingernails were concave.
‘Can I look at your tummy now?’
‘Can I look at yours?’ Charlene asked.
‘Not this time,’ Natalie said with a smile. She definitely wasn’t baring any flesh in front of Kit. ‘But if you want to play doctors while I talk to your mummy, you can look at a doll’s tummy and see what you can hear through my stethoscope.’
Charlene wriggled a bit, but submitted to an examination. Natalie palpated her abdomen gently. She didn’t think there was a problem with the spleen, but maybe she should ask Kit for a second opinion. No sign of petechiae, reddish-purple pinhead spots, which would lead to a more sinister diagnosis. And, she was pleased to note, there were no signs of enlarged lymph nodes in Charlene’s neck.
As soon as she’d finished, Charlene was wriggling around on Ella’s lap again, and Ella pressed one fist into her lower back for support. Natalie gave Ella a sympathetic smile. It must be hard, dealing with small children when you were heavily pregnant and tired.
‘She’s a handful for such a little scrap,’ Ella said, looking embarrassed.
Oh, no. That hadn’t been what she’d intended at all. Or maybe Ella was just used to being defensive about her little girl. ‘Lively, the medical term is,’ Natalie said with a smile. ‘How’s she eating?’
Ella grimaced. ‘She’s picky. She won’t eat any vegetables—she just throws them on the floor—and she doesn’t like anything with meat in it, even if I try to hide it. But I can get her to eat potatoes and eggs, and she drinks milk and fruit juice.’
It was nowhere near a balanced diet, and Ella was clearly aware of it—distressed about it, too, so Natalie decided to take the gentle approach. ‘Kids are notorious for that—one day they’ll eat something, and the next they won’t touch it,’ she said reassuringly. ‘How about you take me through right from the start, from when she was first born?’ She could already see that Charlene had had a low birthweight, something that could predispose her to anaemia. ‘Did she have any jaundice afterwards?’
‘She was a bit yellow, but the midwife said it was normal.’
Natalie nodded. ‘Most babies have it to some extent.’ Though Ethan hadn’t. He’d been a perfect seven and a half pounds. No problems at all. Prolonged jaundice in the newborn could suggest congenital anaemia. ‘How long did it last?’
‘A week or so.’
‘How was she feeding?’
‘I breastfed her for about a week.’ Ella grimaced. ‘I tried so hard, but I just couldn’t manage it. My husband works long hours and it was too much for me. I got so tired—she seemed to be constantly attached to me, just taking little bits here and there, and I never got a break. And I was so sore.’
No support at home, and a husband who wasn’t there more often than not. Yeah, Natalie could empathise with that one. Really empathise. She couldn’t help glancing at Kit— and looked away again the second she met his cornflower-blue gaze. She just hoped she wasn’t blushing. Hell. This was meant to be about her patient, not about her and Kit.
‘So I switched her to formula milk,’ Ella continued.
And felt she’d failed as a result. It was very clear in Ella’s face—guilt, worry that she’d done the wrong thing, that she’d given up at the first hurdle without really trying. ‘Hey, that’s fine,’ Natalie said. ‘I know you read everywhere that breast is best, but you have to do what works for you as a family. Don’t listen to anyone who tries to make you feel bad or says you did the wrong thing. How did she take to formula milk?’
‘OK. I started putting a bit of rice in to her milk when she was two months old, to help her sleep a bit better and stop her being hungry in the night.’
Ouch. That sounded as if Ella had been desperate and had taken advice from the older generation—probably someone who’d gone on and on and on when Ella had been tired, about how Ella had been a baby who had always woken in the night and a bit of rice had never hurt her. Nowadays, the recommendation was to wait until at least four months before weaning.
Careful not to pass
