The Infant
Case 2.3 Growth and Development
36 The Infant
OBJECTIVE
General: Appears thin but alert, active, and playful.
Vital s igns: Weight in the offi ce today is 6.4 kg and his length is 66 centimeters. Kierra ’ s temperature is within the normal range at 36.8 ° C (temporal). Kierra ’ s weight has not changed since her last well child visit.
Skin: She appears well hydrated, and her skin was clear of lesions. There is no cyanosis of her skin, lips, or nails. There was no diaphoresis noted. Kierra has good skin turgor on examination.
HEENT : Kierra ’ s head is normocephalic. Her anterior fontanel is open and fl at (0.5 cm × 0.5 cm). Red refl exes are present bilaterally; and pupils are equal, round, and reactive to light. There is no discharge noted. Pinnae are normal; the tympanic membranes were gray bilaterally with positive light refl exes.
Bony landmarks are visible and there was no fl uid noted behind the tympanic membrane. Both nos- trils are patent. There is no nasal discharge, and there is no nasal fl aring. Kierra ’ s mucous membranes are noted to be moist when examining her oropharynx. She has 2 teeth present — lower central inci- sors. There are no lesions present on the teeth or in the oral cavity.
Neck: Supple and able to move in all directions without resistance. There are no lymph nodes present in the neck area.
Respiratory: Rate is 22 breaths per minute, and her lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No deformities of the thoracic cage noted.
Cardiovascular: Heart rate is 110 beats per minute with a regular rhythm. There is no murmur noted upon auscultation; brachial and femoral pulses are present and 2 + bilaterally.
Abdomen: Normoactive bowel sounds are present throughout; soft and nontender. There is no evi- dence of hepatosplenomegaly.
Genitourinary: Genitourinary examination reveals normal female genitalia.
Neuromusculoskeletal: Good tone in all extremities. She has full range of motion in all extremities and her extremities are warm and well perfused. Capillary refi ll is less than 2 seconds, and his spine is straight.
CRITICAL THINKING
Which diagnostic or imaging studies should be considered to assist with or confi rm the diagnosis?
___CBC count ___Urinalysis ___Urine culture
___Electrolytes, including creatinine and BUN
___Liver function tests, including total protein and albumin ___Barium swallow
___Chest radiograph
What is the most likely differential diagnosis and why?
___Organic failure to thrive ( FTT ) ___Nonorganic FTT (FTT)
___Constitutional growth delay ___Fetal alcohol spectrum disorder
Growth and Development 37
What is your plan of treatment, referral, and follow - up care?
Does this patient ’ s psychosocial history affect how you might treat this case?
What if the patient lived in a rural setting?
Are there any demographic characteristics that might affect this case?
Are there any standardized guidelines that you should use to assess or treat this case?
RESOLUTION
Diagnostic t ests: Many cases of children not gaining weight are nonorganic, so a history and physical examination are normally all that are needed. Certain laboratory tests may help to screen for an underlying pathologic condition. A complete blood count ( CBC ) can be ordered as well as a urinalysis and urine culture. If an electrolyte imbalance is suspected, electrolytes including blood urea nitrogen ( BUN ) and creatinine can be ordered. Liver function tests may also be ordered to rule out an underly- ing liver condition.
If it is suspected that the infant is having a physical problem such as diffi culty swallowing, a modifi ed barium swallow may be ordered. This test would be done under the directions of a feeding therapist and a radiologist. During the test, the infant would be given liquids and solids differing in consistency. The infant ’ s swallows would be fi lmed to determine if there are swallowing diffi culties that are contributing to the lack of weight gain. A chest radiograph would be helpful in assessing whether a cardiopulmonary disease is a contributing factor.
What is the most likely differential diagnosis and why?
Nonorganic failure to thrive:
With an infant who is not gaining weight, there are several differential diagnoses to consider includ- ing organic failure to thrive, nonorganic failure to thrive (FTT), constitutional growth delay, and fetal alcohol spectrum disorder. We do not know much about Kierra ’ s birth and past history — only that she was removed from her mother ’ s care and placed in foster care. Because it is unknown whether or not she was exposed to substances, including alcohol in utero, it would be wise to initially consider a diagnosis of fetal alcohol spectrum disorder as a contributing factor to the failure to gain weight.
Children with true fetal alcohol syndrome display a failure to gain weight, as well as distinct facial anomalies; and they typically have cognitive/developmental impairment. Those with fetal alcohol spectrum disorder may display growth and cognitive delays but may or may not have the distinct facial features that are associated with fetal alcohol syndrome. Given Kierra ’ s history, there was nothing on the physical examination or in the history to indicate that she has distinct facial anomalies or any delays in development. Based on these fi ndings, it is likely that both fetal alcohol spectrum disorder and fetal alcohol can be ruled out as causes for Kierra ’ s growth impairment.
Constitutional growth delay may also be considered in the differential diagnoses for a failure to gain weight. Children with constitutional growth delay may have linear growth velocity and weight gain that slows beginning as early as age 3 – 6 months. We do not have information on this child ’ s linear growth velocity. We have only one length measurement, which would not tell us whether or not the linear growth velocity is stable, increasing, or decreasing. However, most children who have constitutional growth delay do not seek medical attention until puberty, when a lack of sexual devel- opment becomes apparent and a discrepancy in height from peers is noted because of the delay in pubertal growth spurt. This makes it likely that Kierra does not have constitutional growth delay and that her care provider should consider other diagnoses.
Organic FTT usually results from problems such as neuromuscular abnormalities, craniofacial abnormalities, or lack of appetite. Other conditions that may result in organic FTT include breathing diffi culties, signifi cant developmental delay, and primary gastrointestinal disease or dysfunction. The information obtained in Kierra ’ s history and on her physical examination does not indicate that she suffers from any of the aforementioned problems, making organic FTT an unlikely diagnosis.
38 The Infant
Nonorganic FTT usually results from adverse environmental and psychosocial factors. It may be associated with abnormal interactions between the caregiver and the infant. This may result in an inadequate provision of food and/or inadequate intake of food. Nonorganic FTT is most common in the setting of poverty. It may include a combination of poverty and lack of preparation for parenting.
An important part of the evaluation of all children is observation of the infant while feeding.
Observing infants while they are feeding sheds light on maternal - infant interactions. Given Kierra ’ s history and physical examination and the elimination of the previous diagnoses, nonorganic FTT is the most likely diagnosis at this time. Kierra ’ s caregiver has not cared for an infant in the past, so it may be possible that she is unaware of the caloric needs of a 9 - month - old. A 9 - month - old infant needs an approximate caloric intake of 140 kilocalories (kcal)/kilogram (kg) per day. Calculating Kierra ’ s daily caloric needs (6.4 kg × 140 kcal) means that she would need 896 kcal per day. Calculating her caloric intake based on her reported history, Kierra ’ s daily caloric intake is less than her calculated caloric needs. Calories in regular infant formula are 20 kcal/oz. Kierra ’ s stated intake is 24 oz of formula daily, which provides her with 480 kcal/day. She also eats 2 jars of stage 1 baby food daily.
Stage 1 baby foods typically have 25 – 50 kcal/jar, providing Kierra with an additional 50 – 100 kcal per day. Kierra ’ s approximate caloric intake per day is 530 – 580 kcal, far below her daily caloric need of 896 kcal. Also, Kierra ’ s foster mother does not work outside the home and receives several govern- ment housing and food subsidies. Her eligibility for these subsidies makes it likely that she lives at or near the poverty line, a risk factor for nonorganic FTT.
What is your plan of treatment, referral, and follow - up care?
The goal for Kierra would to provide her with adequate caloric intake for growth. In this case, it would appear that Kierra can be treated for her nonorganic FTT on an outpatient basis. However, frequent follow - up visits are necessary (initially at 2 – 4 weeks, then at least monthly thereafter).
Kierra ’ s weight gain, linear growth velocity, head circumference, and daily caloric intake should be recorded at each follow - up visit. Her weight, length, and head circumference should be plotted on the same age - appropriate growth chart over time. Ann should be instructed on proper caloric intake for Kierra and on ways to increase calories in Kierra ’ s diet. Home visits, from the health care provider or an outreach worker may assist in determining the underlying reason for the nonor- ganic FTT.
If outpatient treatment does not lead to documented weight gain, hospitalization may be necessary for diagnostic and therapeutic reasons. When treating an infant with FTT, a multidisciplinary team approach should be used. A pediatric health care provider, nutritionist, and social worker should be a part of the team. A mental health care professional may also be included. This team should complete a thorough evaluation of the family ’ s psychosocial situation and determine if future support is required. A home visit can help to support the caregiver. The family may also be referred to a local food bank if food affordability is a problem.
Does this patient ’ s psychosocial history affect how you might treat this case?
Kierra ’ s psychosocial history does affect how this case would be treated. Kierra is in foster care. It is essential that her foster care worker be informed of diagnosis. Through the state ’ s child protective services, Kierra ’ s foster care worker may be able to provide additional support (social and fi nancial) for Ann. They may also need to determine if Kierra would be better cared for in a foster home where the foster mother is knowledgeable about infant nutrition and care.
What if the patient lived in a rural setting?
If this patient and her foster family lived in a rural setting, having frequent follow - up appointments in the offi ce might not feasible. In that case, the health care provider could consider employing the services of a visiting nurse service to visit the home monthly to monitor Kierra ’ s weight and nutri- tional status. The family ’ s ability to obtain additional food through a source such a food bank may be limited as there may not be one in the area.
Are there any demographic characteristics that might affect this case?
While failure to thrive can occur in any socioeconomic strata, nonorganic FTT is more likely to occur in families living in poverty. There is an increased incidence of nonorganic FTT in children receiving Medicaid, children living in rural areas, and those who are homeless. While the exact reason is
Growth and Development 39
unknown, nonorganic FTT is more likely to occur in females than in males. In regard to age in the pediatric population, the most likely age groups to have nonorganic FTT are infants and toddlers.
Are there any standardized guidelines that you should use to assess or treat this case?
For two guidelines for the detection and treatment of failure to thrive, see Cincinnati Children ’ s Hospital Medical Center (2009) and Block & Krebs (2005) in References and Resources below.
REFERENCES AND RESOURCES
Block , R. , & Krebs , N. ( 2005 ). Failure to thrive as a manifestation of child neglect . Pediatrics , 116 , 1234 – 1237 . Cincinnati Children ’ s Hospital Medical Center . ( 2009 ). Best evidence statement ( BESt ) failure to thrive treatment
protocol. Cincinnati, OH: Cincinnati Children ’ s Hospital Medical Center. http://www.guidelines.gov/
content.aspx?id=14794 & search=failure+to+thrive
Daniel , M. , Kleis , L. , & Cemeroglu , A. ( 2008 ). Etiology of failure to thrive in infants and toddlers referred to a pediatric endocrinology outpatient clinic . Clinical Pediatrics , 47 , 762 – 765 .
Ficicioglu , C. , & An Haack , K. ( 2009 ). Failure to thrive: When to suspect inborn errors of metabolism . Pediatrics , 124 , 972 – 979 .
Panetta , F. , Magazzu , D. , Sferlazzas , C. , Lombardo , M. , Magazzu , G. , & Lucanto , M. ( 2008 ). Diagnosis on a posi- tive fashion of nonorganic failure to thrive . Acta Paediatrica , 97 , 1281 – 1284 .