A 4-day-old term, formula-fed male infant with an uncomplicated prenatal course and no ABO set up or other identified cause of excessive jaundice was admitted to the hospital for phototherapy treatment of hyperbilirubinemia with a peak bilirubin of 19.5. He had an uneventful hospital course and was discharged on day 6 of life.  On day 8 of life, his mother called concerned that he was fussy and had a black discharge from his right ear.  The infant was referred for immediate evaluation at our after-hours care center.

The examining clinician properly PPE attired and with total anosmia from a fitted N95 respirator, noted the black discharge and felt it was consistent with dried blood but was unable to adequately visualize the right tympanic membrane. The patient was noted to have resolved his jaundice and had no fever and otherwise appeared well. However, as the hyperbilirubinemia was unexplained and a possible clue to an underlying infection that may have been the trigger for his jaundice, the infant was sent directly to our Children’s Hospital emergency room.

In the ER, the examining physician wearing a level 1 surgical mask, immediately noted that the discharge had a strong smell of chocolate. Further investigation confirmed the father had been holding the infant while enjoying a Tootsie roll twist!  As both tympanic membranes were well visualized, and the patient had a completely normal exam, he was sent home without further ado and did well.

The benign outcome makes this a “sweet” anecdote but serves as a reminder that our PPE creates new barriers that can interfere with time-honed exam skills. As an example, pediatricians are taught to observe for the smell of acetone when evaluating a dehydrated patient, as a valuable sign of new-onset type I diabetes.

Even more commonly, the facial mask worn by the patient can interfere with the reading of subtle, but often crucial, nonverbal cues.

In a time of intense pressure to increase virtual visits, this case also serves as a reminder of the time-honored value of an in-person encounter.

It is very unlikely that when Dr. Menkes first described maple syrup urine disease, he was wearing an N95.

Michael D. Schwartz is a pediatrician.

Image credit: Shutterstock.com