Cases Without Borders
Without His Mother’s Milk, a Haitian Boy Is Lost
By DENNIS ROSEN, M.D.
PORT-AU-PRINCE, Haiti — I had just sat down after spending most of the morning and the early afternoon in the outpatient clinic at Bernard Mevs hospital here when one of the surgeons came in and said: “You’re a pediatrician, right? There’s a kid at the front gate who’s pretty sick.”
I got up and walked over to the hospital entrance. Because the emergency room had only two beds, and the hospital itself had limited resources, patients were sent through triage at the gate, and only those who could be treated were brought in. The others were turned away to seek care elsewhere.
Arriving at the gate, I could already smell the sharp odor of diarrhea. A young woman was holding a baby wrapped in a stained and tattered blanket. From the interpreter, I learned this was a 5-month-old boy with watery yellow diarrhea, vomiting and a decrease in oral intake during the previous four days.
Opening the blanket and looking at him, I was amazed that he was still alive. His chest looked like a chicken breast picked clean of meat. His mucus membranes were pasty dry, his eyes and fontanel were sunken and his skin hung off his arms and legs as if it were three sizes too large. At 5 months he weighed less than four and a half pounds.
The gastroenteritis, it turned out, was only what had tipped him over. On further questioning we learned that his mother had stopped nursing shortly after he was born because her “milk was bad,” and had been bottle-feeding him with watered-down 7Up soda.
Because he was so dehydrated, his veins had collapsed and the nurses in the emergency room weren’t able to place an intravenous line to give him fluids. It was clear that I’d have to insert a thick needle directly into his shinbone to deliver sterile saline solution with a syringe, an ounce at a time.
Never having done this before (though I had practiced on a raw chicken leg), I was nervous about the procedure. The only needle available was longer than his leg was thick, and I was afraid I would push it through and pin him to the mattress.
He hardly whimpered as the needle entered the tibial cavity with a crunch. We gave him the fluids and admitted him to the pediatric ward, but had no way of measuring his electrolytes. He continued to have severe diarrhea and died several hours after being admitted. While gastroenteritis can be fatal in otherwise healthy infants, his extreme malnutrition had made him more vulnerable, and we were unable to save him.
The Haitian belief in “bad milk” — “lèt gate,” in Creole — is well described by Paul Farmer in his book “Partner to the Poor” (University of California, 2010). It is one of the main reasons for the premature stopping of breast-feeding in Haiti, often with deadly consequences for the infant deprived of safe and dependable nourishment.
That same week, one of the nurses in our group was able to prevent something similar from happening to another infant for whom we were caring. Born a few hours before we arrived, and several weeks before his due date, he, too, weighed less than four and a half pounds.
He was placed in an incubator and given antibiotics, and he seemed to be doing well except for one thing: His mother refused to nurse him, or even to express milk to feed him by bottle. Denise, the nurse who cared for him the week we were there, could not understand why the mother refused so adamantly to feed her son.
She pressed the mother every time she saw her, explaining the advantages of breast milk over formula, until finally the mother explained that a previous child of hers had died in infancy, and that a houngan (voodoo priest) had told her that her milk was no good and that she must never nurse any subsequent babies or else they, too, would suffer a similar fate.
Each day Denise pleaded with her to try to nurse. On the third day, the maternal grandmother came to visit and had a long conversation with Denise, asking whether her daughter’s milk was somehow tainted. Denise assured her it was not.
The next day the mother agreed to try nursing her son. He had difficulty latching on, and she expressed a small amount into a bottle, which he eagerly gulped down.
The following morning she returned, nervous about how he had fared. Once she saw that he was fine, she unbuttoned her blouse and again tried to nurse, this time with better success. Over the next few days she continued to nurse him until she no longer needed to express into a bottle, and looked much more relaxed and in better spirits than she had since he was born.
The difference between breast milk and calorically depleted drinks, or formula prepared from water potentially contaminated with organisms that cause diseases like cholera, can be a matter of life or death. And so encouraging this young mother to give her son the sustenance he needed was a potentially lifesaving intervention, achieved through patience, education and the building of trust.
While it may not sound like much, the sad truth is that in Haiti all of these are hard to come by and remain very much in need.