Case Studies

J.B. is a 19 month-old male who is seen by a pediatric gastroenterologist for evaluation of failure to thrive.
He was delivered at 37 weeks gestation by elective Caesarian section.
Growth records show he grew along the 25-50 th percentile until about 10 months of age, when he fell below the 5 th percentile.
Past medical history was positive for repeated episodes of otitis media.
He had a right leg femur spiral fracture at age 10 months, reportedly from mother’s falling while holding child.
Reported allergies to milk and Amoxicillin.
Systems review : frequent mucous stools 5-6 times a day, without blood, no vomiting
Family history – 3 half-sibs by a previous marriage, all alive and well
Social history – father unemployed, mother college student, positive drug history during pregnancy
Diet history – 16 oz./d (500 ml) Lactaid (lactase-treated) milk, very little solids, avoids all meat and vegetables
Physical exam – unremarkable except for slight cervical adenopathy, liver at 2 cm below RCM, and a palpable spleen tip.
 

Question 1: What are the risk factors for this child to have malnutrition?

  1. Poor growth since 10 mos. of age with hx of previous normal growth.
  2. High-risk social history, including prenatal drug use.
  3. Poor diet intake. Use of Lactaid milk conflicts with report of milk allergy -? lactose intolerance versus true milk allergy. Minimal solids (developmentally behind with oral intake), and avoidance of all meats and vegetables puts him at risk for inadequacies of multiple nutrients in addition to total calories.
  4. Recurrent infections (otitis media) and cervical adenopathy.

Anthropometry:

Weight: 9.295 kg

Length: 75 cm.

OFC: not available

Weight for Length: _____ %
 

Question 2: What is your assessment of his growth parameters?

  1. Wt: 9.295 kg less than 5th%, and is 80% of the standard (50th%) for age
  2. Length: 75 cm less than 5th%, and is 89% of the standard (50th%) for age
  3. Weight for Length: 25th%.
  4. Growth parameters are consistent with moderate stunting, indicating chronic undernutrition.

Plot the patient’s weight, length, and weight for lenght on NCHS growth charts (available at www.cdc.gov) . Is he underweight? Wasted? Stunted?
 

Question 3: What other questions do you have about his history, especially his diet history?

  1. Describe a typical day of eating and drinking for your child. Does he have set meal and snack times?
  2. How long has he been drinking Lactaid milk? What happens if he drinks regular milk? Does he eat other dairy products (cheese, yogurt)?
  3. How was he fed as an infant? What age were solids introduced? When did he begin feeding himself? Who is involved with feeding him? Where does he receive his meals/snacks (at the table, in front of TV, etc.)?
  4. Does he have a routine sleep schedule? Does he sleep in his own bed?
  5. Does he take any vitamin, mineral, or herbal supplements?
  6. How is his activity level? Does he keep up with his siblings and peers?
  7. How would you describe his appetite? Has this changed recently?
  8. Do you have concerns about his eating and growth? When did you first become concerned?
  9. What is your (mother’s) height? What is his father’s height?
  10. The above questions are seeking an explanation for his growth stunting. You want a clear picture of his eating, especially looking for evidence of 1) “nutritional ignorance” – inadequate amounts and types of foods offered, unusual foods or diets, and mistakes in mixing formula; 2) “family chaos” – are there multiple care givers, is there grazing, are there changing times and sites of feeding, is the home environment unstable? 3) “child/parent conflict” – poor eating behavior, meal time disruptions, and poor limit setting by parents. Please refer to the failure to thrive handout provided on this site for additional information.
  11. Obtaining a detailed intake history will also give insight into possible micronutrient deficiencies. Exploring the social history is essential, as there are almost always social factors involved in failure to thrive, whether “organic” or “non-organic” in nature.

 

Question 4: What is your differential diagnosis, and what work up and tests would you do?

  1. The differential diagnosis of failure to thrive can be extensive. It is important to remember, however, that the majority of failure to thrive cases are due to psychosocial problems with feeding and are not due to actual disease. The guiding objective of your evaluation is to seek an explanation for energy and nutrient imbalances – either too little intake or excessive losses. A convenient framework for evaluation is : increased losses (and possibly decreased intake) due to gastrointestinal diseases, such as malabsorptive syndromes, milk or food allergy, celiac disease, inflammatory bowel disease, severe gastroesophageal reflux, infectious diseases (post-viral, Salmonella, Shigella, Yersinia, Campylobacter, parasites) and cystic fibrosis ; increased needs due to malignancy, infectious diseases, cardiac or pulmonary disease; decreased intake due to disabilities, structural anomaly, malignancy, renal disease, or most often due to environmental and behavioral factors.
  2. A chemistry panel to look for acid base disturbances, evidence of renal disease or liver disease, electrolyte abnormalities, and protein status is a simple start. A CBC to screen for anemia and other hematologic (and oncologic) processes is also indicated.
  3. Microscopic examination of a stool sample looking for split and neutral fat can serve as a quick screen for malabsorption, which is important to rule out.

Laboratory values and test results

serum sodium 139, potassium 4.2, chloride 104, CO2 26.5, calcium 9.8, phosphate 7.4 (normally higher in infants than adults), magnesium 1.9, BUN 23, creatinine 0.4, total protein 6.7, albumin 4, bilirubin 0.1, ALT 22, AST 28, all within normal limits.

CBC: hemoglobin 11.6, WBC 12.1, platelets 307000, sedimentation rate 8.

Anti-endomysial antibodies <2.5, anti-reticulin antibodies<1:40 negative to rule out Celiac Disease.

Gliadin antibodies IgG 11.1, IgA 3.6 negative

Sweat chloride negative for cystic fibrosis

Stool cultures negative

Stool ova parasites negative

Fecal fat 3 day collection 282g/3d, 0.4.g/d fat, <1% no malabsorption

Endoscopy and biopsies: gastric antrum normal, duodenum focally reactive mucosa with antral metaplasia, no villous atrophy or inflammation, colon mild eosinophilic infiltration

Upper GI series X-rays normal

pH probe for reflux normal
 

Question 5: With his stool studies, labs, and endoscopy report, how do you explain his mucosy stools, and is this clinically relevant?

  1. He has no evidence of malabsorption or inflammation. His mucousy stools may represent toddler’s diarrhea, and may also be from his poor diet and poor nutritional state. His stools are likely a symptom of his failure to thrive, and not a cause of it. Once his intake is improved, it will be important to monitor the character and frequency of his bowel movements.

 

Question 6: The temptation to do multiple and often invasive testing is great, especially once a child is referred to a specialist for evaluation. Of the tests run, are there any that possibly could have been held pending the results of other interventions or work-ups?

  1. The sweat test for cystic fibrosis, pH probe, upper GI series x-rays, endoscopy, and 3 day fecal fat tests all probably could have been deferred until more was known about his dietary, developmental, and social history. These tests are indicated in response to specific findings – e.g. fat in stool, complaint of abdominal pain or vomiting, etc. For the majority of cases of undernutrition in an otherwise healthy appearing child, a thorough history is the most revealing component of the evaluation.

Hospitalization

On hospitalization for observation, oral calorie counts averaged 37 kcal/kg/d for 3 days. He was started on oral Pediasure (a non-elemental 30 calorie/ounce supplemental formula), but only took 8-24 oz/day and did not gain weight.
 

Question 7: How would you assess his intake compared to his calorie/protein needs?

  1. His intake is grossly inadequate – He is not even meeting the RDA for age of 100kcal/kg, and likely needs closer to 125 kcal/kg to “jump start” his growth.

 

Question 8: What is your diagnosis at this point for his failure to thrive?

  1. His failure to thrive appears to be due to inadequate oral intake likely compounded by a chaotic social environment. (Of note, however, the hospital environment is a foreign and intimidating one to a young child and is rarely found to be a good setting in which to optimize oral intake).

Additional workup:

Phenolphthalein screen negative for laxatives (Munchausen by proxy syndrome)

Growth and Development consultation noted inadequate nutrient consumption by mouth, poor oral muscle strength, poor physical endurance for play, and excessive sleep pattern during the day. Child Psychiatry, Social Service, Genetic analysis and other information established that the mother’s boyfriend was not the biologic father as claimed. He thus did not have any custody rights, and with a history of criminal activity and suspected abuse (the femur fracture), the court issued a restraining order against him.
 

Question 9: Outline your treatment plan for his failure to thrive. How would you approach feeding him?

  1. He needs continued involvement of social services, and would also benefit from occupational (for oral motor issues) and physical therapy (for endurance issues) consults.
  2. Because he exhibits moderate growth stunting, and is having difficulty with oral intake, it was decided to trial supplemental nasogastric feedings. A tube was placed, and he was given drip feeds of Pediasure with Fiber 60cc/hour for 10 hours overnight to provide him with about 50% of calorie needs by tube. He was encouraged to eat a structured three meals and two snacks each day. His mother was counseled on high calorie age appropriate foods to give him, and how to set limits and promote a positive environment for eating. At the time of discharge two weeks later, he had gained 655 grams to 9.95 kg. He had a percutaneous endoscopic gastrostomy tube placed, and did well on supplemental feeds at home, with intake by tube gradually decreased as his oral intake improved. His growth eventually returned to the 25-50th%. The PEG was removed 18 months later. He and his mother have since rejoined her first husband and daughters.
  3. Approaches to therapy for undernutrition can differ in such cases. Some would consider outpatient behavioral therapy with or without nasogastric feedings prior to placing a PEG. The demonstration of weight gain in the hospital with tube feedings verifies that, given adequate caloric intake, the child is able to gain – i.e., that there was no pathologic “organic” process underlying the poor growth.
  4. It is important to note that in setting goals for treating failure to thrive, and especially growth stunting, that the return to previous growth curves may not occur. Success should instead be defined as: 1) a return to normal development, 2) the establishment of healthy eating patterns and behaviors, 3) a reverse in the growth “faltering” on the growth chart, and 4) less parental anxiety over feeding and growth issues.