On the train back down from upstate yesterday, across from me sat a mom and her son — about 6 months old. Per the suggestion of my critical care professor and because I’m rotating with pediatric neurology right now, I observed the young boy as he cried from hunger, fed a bit, then played with his mom. I thought of the thoughts and neural connections buzzing through his brain in that moment. His curious eyes darted around studying the faces of passengers, realizing that they’re faces and we’re people. He squinted when light shone through the autumn trees whistling by outside the window. He grasped at hair and clothes and with his clumsy fingers, instinctively bringing them to his mouth. As his mom lifted him by the shoulders, he pulled his legs underneath him to strengthen his hip and knee extensors. He heard his mom’s teasing voice chanting “I’m gonna get ya! I’m gonna get ya!” and his brain captured this pattern of vibrating air molecules as samples of language for future decoding. Baby brains are outright miracles.

Well, that’s provided that their brains in good working order. A consequence of working with inpatient peds neuro (at a preeminent hospital in America’s biggest metropolis) is that I meet those rare kids with “bad brains.” “Bad brain” is a term thrown around loosely among the housestaff. I know it sounds bad, but it’s not meant to be derogatory. I hear them use “bad brain” like a lament, a piteous label; for instance, “listen, you can only do so much for her, but she’s going to keep seizing no matter what. She’s got a bad brain.” And although we do our best not to let a disease process define our patients in our minds, the term is just so efficient. They say “bad brain,” and so much is communicated.

These kids with “bad brains” have had grievous insults inflicted upon their brains. It varies from congenital malformations to trauma to “hypoxic-ischemic encephalopathy,” when adequate bloodflow to the brain is interrupted sometime around birth and some of the brain dies. Etiologies range from complicated deliveries to genetic syndromes, from congenital malformations to preterm babies. The neuroimaging can look pretty horrifying. Their brains are shrunken and shriveled in odd places when it should be plump and growing to fill an expanding skull; they have splotches of dark in matter that should look white and streaks of brightness where they should be dark. In short, their brains have been ravaged. Many of them have bradycephaly, or flat head syndrome, because the kids lie with their heads back without moving.

And they’re just… gone. When a brain never has the chance to develop, there’s no recovering it. The kid is permanently developmentally delayed, or worse. For instance, a 3-year-old born with an obscure genetic syndrome will continue to grow a bigger body, but she is frozen at the developmental stage of a 3-month old, destined never to walk or talk or interact meaningfully with her family. For unknown reasons, a 2-month old infant has seized his brains out for days at a time, frying his brain in the process, so he’s also going to be globally developmentally delayed. The most jarring kid I met was the 6-year-old strapped to a stretcher wheeled in by an ambulance from the facility where he lives. He was the size of a 3-year-old (the attending couldn’t believe his weight when calculating med doses), with his feeding tube tucked under his clothes, permanently hooked up to oxygen. He’s blind, deaf, heavily sedated, seizing anyway, unable to walk, unable to feed himself, and non-communicating. The nurse aide who brought him said maybe he can roll over? He gets wheeled out every year so the neuro clinic can tweak his meds, then returns to his facility. His parents don’t visit anymore. I asked the resident what is this poor kid’s prognosis. Apparently, he will just go back to the facility in that condition where he will be sustained by health workers there, funded by taxpayer dollars, until something iatrogenic like aspiration pneumonia or a medication dosing error kills him sometime. ::sad face::

At least the kids look content, unperturbed, lying there with unseeing eyes. They’re fed well, kept warm, and cared for medically. When stimulated, they flail at random, unaware of the lamenting family and healthcare workers standing over them. I think — well, I hope — that their bad brains don’t comprehend that they were supposed to mature. I hope in that ignorance there is bliss.

PS. I delayed posting this because it felt so politically incorrect. It’s a naked condemnation of poor innocent babies for which nothing can be done. I didn’t even have the will to explore the views of the parents or dedicated healthcare workers. All I can offer is empty pity and morbid voyeurism… Thankfully, peds neuro is quite often uplifting because — well — baby brains are miracles! ::happy face::