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I scanned the patient’s chart: “14-month-old boy with a cold, not eating.” The child’s father, a brown-skinned man in his forties, held his son in his lap. The baby was listless, his skin a pale yellowish-white. Jaundice1 was my first suspicion. |
我浏览了一下病人的病历表：“14个月，男孩，患有感冒，厌食。”孩子的父亲是个棕色皮肤的男人，40多岁，搂着大腿上的孩子。孩子无精打采，皮肤苍白而微微发黄。我首先怀疑孩子得了黄疸。 |
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After introducing myself, I asked the father, “Does your son have any medical problems?” |
自我介绍后，我问这位父亲：“您儿子有大病吗？” |
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He answered slowly, with the accent of his native Philippines: “My son has asthma2.” |
他操着菲律宾本土的口音慢腾腾地回答说：“我儿子患有哮喘。” |
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Asthma does not cause jaundice. The boy’s lips were pale, almost gray, with no pink color at all. His fingernails, too, were so pale they looked almost chalky. Normally, his skin color would have been much like his father’s, a rich, light yellowish-brown, but all the red and pink tones had vanished. This baby was probably severely anemic3, which meant he was low in oxygen-carrying red blood cells. But asthma doesn’t give you anemia either. |
哮喘不会引起黄疸。孩子的嘴唇苍白中透着灰暗，没有一点血色。他的手指甲也是惨白惨白的，活像白垩一般。正常情况下，他的皮肤本该像他父亲的一样，呈现一种鲜亮的棕黄色，然而，所有的血红色调已全部消失。该婴儿很可能患有严重的贫血症，这说明他的携氧红细胞含量低。但是哮喘也不会导致贫血。 |
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The baby was breathing somewhat rapidly, and I heard a few wheezes4, but I saw no sign of a breathing obstruction. The boy gazed at me, slumped5 in his father’s lap, hardly moving. |
这个婴儿呼吸有些急促，我还听到几次艰难的呼吸，但我并没有观察到呼吸障碍物的迹象。他萎靡不振地呆在父亲的大腿上，一动不动。 |
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When I checked the computer for his medical records, the most recent entry gave me a jolt. Four months ago, he was admitted to the hospital with the diagnosis “asthma with acute respiratory6 failure”—a serious and sometimes fatal condition. Fortunately, the boy had recovered fairly quickly. |
我从计算机上调出他的病历记录，最近的一条记录吓了我一跳：四个月前他被医院收治，诊断为“哮喘伴有急性呼吸衰竭”——一种严重的病症，有时会导致死亡。幸运的是，这个孩子恢复得相当快。 |
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I listened to his lungs again. Although they didn’t sound bad, I called to the nurse: “Let’s check his oxygen. Give him oxygen if he needs it, and let’s also give him an albuterol7 breathing treatment.” |
我又听了听他的肺部。虽然他的肺听起来并不坏，但我还是向护士吩咐道：“咱们检查一下他的氧气供应情况吧，如需要，就给他输氧，同时还可以利用沙丁胺醇雾化吸入治疗。” |
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I wasn’t going to take a chance. Although the boy’s asthma seemed mild, I would treat it aggressively, hoping to head off8 a severe episode. Still, I wondered, why was he so pale? |
我不打算冒险。虽然孩子的哮喘看来是轻微的，但是我仍想予以积极的治疗，以期避免严重的情况发生。尽管如此，我仍然纳闷：他为什么如此苍白？ |
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The only medication he was taking was for his asthma. The father added that the boy had been pale and lethargic9 for the last two or three months. He had not been eating—only drinking milk. He no longer babbled10, and he had lost interest in crawling or walking. |
他仅仅服用了治哮喘的药物。这位父亲又说孩子在过去的两三个月中肤色苍白而昏昏欲睡，一直不吃饭——只喝牛奶，他不再咿呀学语，对爬行和步行也失去了兴趣。 |
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Was some progressive disorder causing anemia and affecting his brain? Leukemia11 could do that, as could some other rare disorders. I examined the boy for signs of leukemia or another malignancy12, like an enlarged spleen13, swollen lymph nodes14, or signs of bleeding in the skin. Fortunately, I saw no warning signs. I also checked to see if the anemia had progressed to the point that his blood no longer carried enough oxygen for his body’s needs. His heart and lungs were working hard, but he didn’t seem in immediate danger. |
是否某种进行性疾病引起了贫血并影响到他的大脑？白血病及其他一些罕见疾病都会造成这种情况。我检查了这个男孩，看看有无患白血病或其他恶性疾病的征兆，象：脾肿大、淋巴腺肿胀或皮肤出血等现象。幸运的是并没有发现预兆病征。我又对他进行了检查以便确定他的贫血症是否已经恶化到这种地步—自身的血液不能携带足够的氧以供身体所需。尽管他的心脏和肺脏在吃力地工作着，但是看来他不会马上就有危险。 |
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When I saw that he was stable, I sent him for tests to determine the level of hemoglobin15—the oxygen-carrying molecule—in his blood. The results would show the severity of his anemia. Normally, a 14-month-old’s hemoglobin is around 10 to 13. A few minutes later, the lab clerk called. |
看到他稳定下来后，我就派人去为他化验，以确定血液中血红蛋白，即携氧分子的含量。化验结果会显示其贫血的严重程度。正常情况下，14个月的孩子血红蛋白含量大约在10到13之间。几分钟后，化验室工作人员打来电话： |
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“Dr. Cohen, we have a critical value16. The hemoglobin is 2.2.” |
“科恩博士，我们得出一个危急值——血红蛋白含量为2.2。” |
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The lowest hemoglobin I’d ever seen in a child was 3.6 in a 3-year-old girl with pneumonia17. She had stopped breathing right in front of me. The lung infection had overwhelmed her body’s ability to make up for the anemia that compromised her oxygen supply. Luckily, we were able to treat her, and she did fine. |
此前，在小孩子中，有一个患肺炎的三岁女孩是我所见到的血红蛋白含量最低的，为3.6。在我面前她就停止了呼吸。贫血危及氧气供应，而她肺部感染严重，已经摧毁了自身弥补贫血症的能力。还好，我们能够对她实施治疗，她情况好转了。 |
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I told the boy’s father that his son needed hospital care. I also explained that severe anemia had sapped his energy to walk and talk. |
我告诉男孩的父亲，这孩子需要住院治疗；我还解释说是严重的贫血症使他逐渐地丧失了行走和说话的力量。 |
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When I saw the child’s full lab report, I was relieved to see that his white blood cells and platelets18 were at normal levels. No leukemia. The analysis also noted, however, that his red blood cells were small, lacking in color, and in some cases unusually shaped. Problems in red blood cell formation can occur because of genetic diseases or more often because of a lack of iron in the diet. Red blood cells are packed with hemoglobin, and each hemoglobin molecule requires four oxygen-binding iron atoms. In the absence of sufficient iron, red blood cells cannot form properly. |
看到这个男孩完整的化验报告后，发现他的白细胞和血小板都处于正常水平，我感到宽慰：他没得白血病。然而，经分析还发现他的红细胞偏小、色浅，而且有的形状异常。在红细胞形成的过程中出现问题，可能是由于遗传病，或者由于更为常见的原因—饮食中缺少铁质。红细胞中充满了血红蛋白，而每个血红蛋白分子需要四个结合氧铁原子。在铁质不足的情况下，红细胞不能正常地形成。 |
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The pieces came together when the father told me the boy had been consuming almost nothing but milk for many months. Cow’s-milk protein can cause a low-grade inflammation19 in the intestinal lining20. Although the irritation is not enough to trigger pain or vomiting, it does cause microscopic bleeding. If the blood loss goes on long enough and the child is not consuming any iron-containing foods or supplements, profound anemia is inevitable. Children under the age of 3 are particularly vulnerable because the protective intestinal lining hasn’t fully matured. |
这位父亲告诉我，很长时间以来，这孩子除了喝牛奶之外几乎什么都不吃。这时，可以把零散的病因汇总起来了：牛奶蛋白质会在肠道内引起轻微的炎症，这种炎症刺激不足以产生疼痛或呕吐，但确实可以引起极少量的出血；如果失血持续很长时间，孩子又不吃含铁食物或含铁补剂，那么严重贫血是不可避免的；三岁以下的孩子特别容易受到伤害，因为肠道的保护机制尚未完全发育成熟。 |
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Doctors routinely tell parents not to give whole cow’s milk to infants until their first birthday and instruct parents at the 1-year-old well-child visit to make sure their child is taking in a variety of foods, not just milk. For some reason, this baby’s parents hadn’t gotten the message. Perhaps his severe asthma had preoccupied21 both his doctors and his parents. Fortunately, he quickly responded to a blood transfusion. The following day he was much more active and alert. Before he went home with his parents, they were counseled about diet and given iron supplements to build up the boy’s iron stores over the next two to three months. After that, he would take regular vitamins with iron. |
医生通常告诉家长们，在婴儿一周岁之前不要让他们喝全脂牛奶；对带着一周岁健康的孩子来看医生的家长，医生常常叮嘱:要确保孩子饮食多样化，不要只喝牛奶。不知什么原因，这个孩子的父母没有得到这条信息。也许是严重的哮喘转移了医生和孩子父母注意力。幸运的是他对输血的反应很敏感，第二天他就活跃多了，也机灵多了。孩子随父母回家之前，医生在饮食方面对他们给予劝告，并给他们开了铁质补充剂，以增加孩子在接下来两三个月中的铁质储备量。此后他还要不断地服用含铁维生素。 |
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Many parents worry when a toddler doesn’t like milk. I tell them about other sources of calcium like soy milk or calcium supplements. And I tell them about the babies who become anemic from drinking nothing but milk: “Cow’s milk is not an essential nutrient, unless you’re a calf!” |
当学步儿童不喜欢喝牛奶的时候，很多家长都表示出担心，我就跟他们谈谈其他的钙质来源，象：豆奶或钙质补充剂。我还跟他们谈及除牛奶外什么都不喝的孩子患上贫血症的情况：“牛奶不是一种必要的营养品，除非您的孩子是头小牛！” |
