Opinion ID: 1847492
Heading Depth: 1
Heading Rank: 3

Heading: xavier's premature birth and subsequent hospitalizations

Text: Xavier was born at approximately 27 weeks' gestation. By all accounts, Joanna's pregnancy with Xavier was difficult. During the pregnancy, Joanna was treated several times for dehydration. Joanna's obstetrician, Dr. Sean Kenney, utilized both NG tube and J tube feedings in an attempt to help Joanna keep food down and gain appropriate weight. An NG tube delivers nourishment directly to the stomach; a J tube bypasses the stomach and delivers nourishment directly to the intestines. According to Kenney's testimony, about 2 weeks after beginning the J tube feedings, Joanna stopped the feedings because she reported the feedings made her feel nauseous. However, because such feedings bypass the stomach, usually no nausea is experienced. Joanna was directed to restart the feedings, but did not do so. Joanna subsequently requested the removal of the J tube, but Kenney declined to remove it. Kenney testified that he did not want to remove the tube because, given Joanna's inability to gain weight, the tube might still be needed. During Kenney's treatment of Joanna, he expressed concern that Joanna was suffering from an eating disorder. Joanna had spent much of her youth in various forms of treatment for anorexia nervosa. Kenney recommended more aggressive care, but because both Ben and Joanna denied that Joanna was suffering from an eating disorder, such treatment was refused. Joanna was eventually hospitalized on September 24, 2006, and remained so until Xavier's birth on October 31. During her hospital stay, Joanna still did not gain weight as expected. No medical reason could be found for this failure. However, on two occasions, a nurse discovered that Joanna's feeding tube had been disconnected. Kenney also testified that during this hospital stay, Ben and Joanna repeatedly stopped and restarted the tube feedings. Following Xavier's birth in October 2006, he spent 2 months in the neonatal intensive care unit at St. Elizabeth Regional Medical Center in Lincoln, Nebraska (St.Elizabeth). According to one of Xavier's physicians, his medical course was uncomplicated while in the intensive care unit and Xavier gained weight appropriately. Upon Xavier's discharge on December 23, 2006, Ben and Joanna were informed that some of Xavier's feedings needed to be supplemented with human milk fortifier. Ben and Joanna were provided a can of human milk fortifier containing a 2- to 3-week supply and were instructed on its use. Just 3 days later, however, Ben and Joanna indicated to Xavier's physician, Dr. Alicia Cruce, that they were not feeding Xavier as ordered. Once home from St. Elizabeth, Xavier failed to appropriately gain weight. He was again admitted to St. Elizabeth on January 10, 2007. Due to Xavier's lack of weight gain, Cruce increased the number of fortified milk feedings from two per day to three per day. During this hospitalization, Xavier gained weight well. Xavier was discharged from the hospital on January 17, but by this time, Joanna had been admitted to St. Elizabeth for a purported flareup of Crohn's disease. Throughout these events, and in the medical records from this case, Joanna asserted that she has Crohn's disease; however, testing has determined it is unlikely that she has the disease. While hospitalized, Joanna was treated with morphine for pain. As a result, Joanna was informed by a nurse assigned to her that she should not breastfeed and that she should pump and dump any breast milk she produced during the time she was on the morphine. According to the nurse, 12 percent of a morphine dose would be transmitted via the breast milk, or about twice the dosage a child of Xavier's age should receive. However, the nurse testified that he observed Joanna breastfeeding Xavier. Another nurse testified that she also saw Joanna apparently breastfeeding at a time when she was on morphine. Despite indicating her understanding of the instruction to pump and dump the breast milk, Joanna kept 6 to 10 cups of what appeared to be breast milk, marked with her name and the word morphine, in a common refrigerator located at St. Elizabeth. The milk was disposed of only after one of Cruce's medical partners was contacted. That doctor spoke with Joanna, then instructed nursing staff to pour the morphine-tainted milk down the sink. Ben and Joanna deny that either was initially informed of the dangers of Joanna's breastfeeding Xavier while she was on morphine. Joanna testified that once she was informed that she should not breastfeed, she stopped doing so. Joanna testified that there was no intention to save the breast milk pumped while Joanna was on morphine, but that she and Ben believed that breast milk, whether or not it contained morphine, was a biohazard that had to be properly disposed of. According to both Ben and Joanna, special steps had to be taken at Children's to dispose of such milk. However, several nurses, including Ben's mother, who is a licensed practical nurse in the St. Elizabeth neonatal intensive care unit, testified that at St. Elizabeth, the milk could simply be poured down the sink or toilet. Joanna was subsequently discharged. But on January 30, 2007, Xavier was readmitted to St. Elizabeth for poor weight gain. That day, Ben and Joanna informed yet another nurse that they were only breastfeeding Xavier. That nurse testified that she asked about the fortified milk and that the parents avoided answering her question, but reaffirmed that Xavier was getting breast milk. However, Ben and Joanna later insisted to Cruce that Xavier was, in fact, getting the prescribed three bottles of fortified milk. The next day, January 31, 2007, Cruce contacted Child Protective Services. Cruce expressed concern that Ben and Joanna were not adequately feeding Xavier, because he would gain weight in the hospital but not at home. Cruce could find no medical explanation for Xavier's continued lack of weight gain. Child Protective Services met with Joanna at St. Elizabeth on February 2 and obtained Joanna's signature on a safety plan which indicated she would follow doctors' orders regarding Xavier's feedings. Ben signed that same safety plan on February 9. On February 16, 2007, Xavier was brought to St. Elizabeth with parental reports of diarrhea and vomiting. Dr. Michelle Walsh, a medical partner to Cruce, admitted Xavier to the hospital due to his low glucose levels. However, Walsh questioned Ben and Joanna's reporting, because diarrhea or vomiting will cause a drop in carbon dioxide levels and Xavier's levels were normal. In an attempt to raise his glucose levels, Xavier was given fluids intravenously and blood was drawn and tested every 2 hours. After several hours, Xavier's glucose levels were still not acceptable. It was then reported to Walsh that Xavier's intravenous line had been disconnected on two separate occasions. Walsh testified that Xavier could not have disconnected it himself; that in Walsh's 10 years of practice, she had never seen a disconnect in a patient Xavier's age; and that in both instances, Joanna was the only person in Xavier's room around the time of the disconnects. During this hospitalization at St. Elizabeth, it was determined that Xavier suffered from hydrocephalus, or extra fluid in his brain. Xavier was transferred to Children's for treatment of the hydrocephalus and placement of a shunt. During this hospitalization at Children's, parental reports of vomiting and fussiness were made, but never confirmed or observed by Children's staff. Xavier was discharged on February 23, 2007, but readmitted on February 27 and 28 for surgery to repair an inguinal hernia. A few days later, on March 2, 2007, Xavier was yet again admitted to Children's due to his failure to appropriately gain weight. Various tests were performed in an attempt to determine why Xavier was not gaining weight, but no medical reason could be found to explain this failure. During the course of this testing, an NG tube was placed. Such a tube runs through the nasal passages, down the back of the throat, and into the stomach. According to Dr. Jay Snow, one of Xavier's treating physicians at Children's, Xavier's condition was progressing toward the need to perform a fundoplication, a surgery in which the top part of the stomach is wrapped around the esophagus, as well as placement of a gastrostomy button (G-button), before it was determined that Xavier's feedings were being interrupted. On March 19, 2007, a 2-week feeding trial using the formula Neocate was begun and Xavier was fed via an NG tube. At the end of the tube were two ports: a main port and a side port. The tube is capped when not in use; when in use, the tube is connected via the main port to a bag containing formula (or whatever is being fed to the patient). The side port is generally used for administering medicine. Even before the beginning of this feeding trial, several nurses reported that the NG tube was being manipulated and that formula was leaking out of the tube or that burp rags were wet with reported emesis, or spit up. Tests conducted on March 22 concluded that Xavier was starving. At that time, a decision was made to have a nurse present in Xavier's room at all times to monitor whether Ben or Joanna were manipulating the feedings. During this time, nurses reported several instances in which it appeared that Xavier's NG tube was being manipulated. After 2 days, Children's ceased such monitoring and contacted the Omaha Police Department (OPD). Beginning on March 29, 2007, OPD began conducting a video surveillance of Xavier's room. During the approximately 7 hours when the room was under surveillance, a detective with OPD observed Joanna disconnect Xavier's feeding tube 25 times and tamper with the tube another 12 times. The detective ceased surveillance and transported Joanna to OPD headquarters for questioning. During that questioning, Joanna admitted that she typically would disconnect Xavier's tube about eight times per day and let the tube drain for 10 to 15 minutes each time. Joanna admitted, contrary to the video evidence, that she had disconnected the tube only twice on that day. Joanna was specifically asked if she or Ben were giving Xavier any breast milk; she replied that they were not and that she was saving it all. Ben, who was not present in Xavier's room at the time of the surveillance, was also interviewed. Ben first indicated that he or Joanna would pour formula from the refrigerator onto the burp rags as evidence of Xavier's continued emesis. But Ben eventually acknowledged that the couple had disconnected the tube and drained food from it. Ben stated that the tube would be drained for up to an hour at a time. In contrast to their statements to OPD, Ben and Joanna both testified at the termination hearing that they were adding breast milk back into the feeding tube using a syringe. Joanna also testified that she occasionally would breastfeed Xavier. Joanna indicated that they hid these actions from hospital staff. Ben testified that he and Joanna would occasionally present formula-soaked burp rags to the hospital staff and represent that it was Xavier's natural emesis in an attempt to stop the Neocate trial. Ben explained that he and Joanna were concerned because the Neocate contained corn, to which Ben claims Xavier was allergic. Ben and Joanna were arrested for child abuse. Both eventually pleaded no contest to felony child abuse. Meanwhile, Xavier remained at Children's for several days following the arrests of Ben and Joanna. During that time, Xavier showed steady weight gain, first on Neocate, then later, on another formula. All NG tube feedings were ceased only days after Xavier was removed from Ben and Joanna's custody. Since his discharge from Children's in April 2007, Xavier has been hospitalized one time, for treatment of a relatively common respiratory virus. Xavier has gained or maintained his weight since that time, and has since switched to a regular diet including whole milk. In addition, Xavier has had tubes placed in his ears and his shunt has been replaced. The ambulance was called on one occasion because Xavier was crying, coughing, and possibly having a seizure. Otherwise Xavier's office visits to Cruce have been for routine well-child checks or for seasonal-type illnesses. There was testimony from several physicians about the effect on Xavier of the disconnection of the feeding tube. Snow testified that Xavier was being starved and that he would have had hunger pains. Snow further testified that children who are starved have developmental delays. He also testified that cognitive functioning can be affected. According to Snow, a younger infant is at greater risk for these problems. A pediatric gastroenterologist, who is a feeding and growth specialist from Children's, testified that a child Xavier's age who is starved suffers problems with brain development and with the immune system. Another doctor, also from Children's, testified that such starvation can cause mild to significant developmental delays and an increased risk of infection and that the younger the age, the greater the effect the starvation will have on a child.