LITMIR.BIZ

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      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 judgment, Natalie asked, ‘What happened then?’

      ‘She slept through, but she dropped a bit of weight then, and when she was three months the health visitor said maybe we’d be better off with a soya-based formula.’ Ella bit her lip. ‘But her charts still kept doing down.’

      ‘Do 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

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