Weight Loss
Weight Loss: Excerpt from The 5-Minute Pediatric Consult
Mark F. Ditmar, MD
Weight Loss - BASICS
Weight Loss - description
A documented decrease in weight from a previous measurement. Outside of the newborn period (weight loss in the 1st 2 weeks is common), acute illnesses resulting in fluid loss, and obese adolescents voluntarily on a designed weight reduction program, weight loss is an unusual and worrisome symptom, regardless of the percentage decline.
Weight Loss - DIAGNOSIS
- Determine the acuity or chronicity and severity of weight loss, and the need for hospitalization.
- Attempt to narrow the diagnostic possibilities by history and examination, particularly by assessing if the loss might be attributable to diminished intake, diminished absorption, or increased requirements.
Weight Loss - signs & symptoms
Weight Loss - history
- Determine that weight loss is real and not to scale error, different scales, different technique (e.g., clothed versus unclothed).
- Child’s diet: A prospective 3-day dietary record can be useful for demonstrating insufficient caloric intake.
- Patient <2 weeks old: Physiologic weight loss, underfeeding, inappropriate feeding, inborn errors of metabolism, congenital heart disease, gastroesophageal reflux
- Patient <4 months old: Malnutrition, improper formula preparation, cystic fibrosis, gastroesophageal reflux, pyloric stenosis, congenital heart disease, congenital adrenal hyperplasia, inborn errors of metabolism
- Patient 4 months to 8 years old: Chronic infection, cystic fibrosis, malabsorption, neglect/abuse, renal disease, liver disease, diabetes mellitus
- Patient >8 years old: Eating disorder, chronic infection, neoplasm, renal disease, liver disease, substance abuse, diabetes mellitus, inflammatory bowel disease, collagen vascular disease
- Cramping, bloating, or abnormally greasy, voluminous stools: Possible malabsorption
- Vomiting, especially projectile: Suggestive of intestinal obstruction, gastroesophageal reflux, inborn errors of metabolism
- Polyuria, polydipsia, and polyphagia: Possible diabetes mellitus
- Headaches, especially early morning: Possible increased intracranial pressure, CNS malignancy
- Maternal history of multiple miscarriages, neonatal deaths, or consanguinity: Possible inborn error of metabolism
- History of severe infections, persistent candidal infections: Immunodeficiency, congenital or acquired
- Fear of fatness, preoccupation with food, distorted body image, and/or amenorrhea: possible eating disorder
- Delayed puberty: Suggests chronic severe weight loss, pituitary abnormalities, anorexia nervosa
- Foreign travel: Possible chronic infection (e.g., tuberculosis, parasitic disease)
- Tiring during feeding or difficulty feeding owing to cough and dyspnea: Suggests congestive heart failure in newborn/infant, hypothyroidism
- Increased appetite with weight loss: Suggests hyperthyroidism, cystic fibrosis, pheochromocytoma
- Altered mental status, seizures, unusual body/fluid odors: Inborn error of metabolism
- Chronic sadness or irritability; insomnia, or hypersomnia: Depression/affective disorder
Weight Loss - physical exam
- Clubbing: Suggests chronic cardiac, pulmonary, or intestinal disease
- Significant abdominal distension: Suggests celiac disease
- Hypothermia, bradycardia: Suggests anorexia nervosa, hypothyroidism
- Tachycardia, resting: Hyperthyroidism, pheochromocytoma, anemia, acute weight loss
- Orthostatic changes: Significant weight loss, possibly acute
- Hypotension, resting: Addison disease, anorexia nervosa, significant acute dehydration
- Visual field abnormalities: Suggests possible CNS malignancy
- Swollen joint: Juvenile rheumatoid arthritis, inflammatory bowel disease
- Muscle weakness: Connective tissue disorder, electrolyte abnormality, muscular dystrophy
- Enlarged liver and/or spleen: Suggests malignancy, chronic infection, storage disease, inborn error of metabolism
- Be certain that the weight loss is real. In some studies, up to 25% of weight loss is an artifact as a result of measurement errors (e.g., excessive movement of scale, dressed versus undressed patient).
- Newborns with weight loss, especially at the 2-week visit, may manifest passivity and paradoxical lack of interest in breast-feeding, although the reason for their problem is malnourishment owing to inadequate intake (often from improper positioning or too infrequent feedings). They may not act “hungry.” Observation of the feeding technique (by a practitioner with expertise or a lactation consultant) is vital.
Weight Loss - tests
- CBC for evidence of:
- Anemia—macrocytic associated with folate/BPolycythemia—suggestive of chronic pulmonary or cardiac disease
- Neutropenia—suggestive of hematologic malignancy, Schwachman syndrome, immunodeficiency
- Lymphopenia—suggestive of immunodeficiency
- Eosinophilia—suggestive of parasitic disease
- Leukocytosis—suggestive of infection
- Thrombocytosis—suggestive of chronic infection, malignancy
- Lymphoblasts—suggestive of leukemia
- Erythrocyte sedimentation rate: May be elevated in inflammatory bowel disease, chronic infections, rheumatoid diseases
- Serum electrolytes: Abnormalities in dehydration, adrenal insufficiency (low sodium, high potassium), renal disease, anorexia nervosa
- BUN, creatinine: Abnormal in renal disease, dehydration
- Stool for occult blood and pH, reducing substances (Clinitest):
- Occult blood suggests inflammatory bowel disease.
- Low pH and positive reducing substances suggest malabsorption.
- Urinalysis:
- Hematuria and/or proteinuria suggest renal disease.
- Glycosuria suggests diabetes mellitus.
- Very low specific gravity suggests diabetes insipidus, chronic renal failure, hypercalcemia.
- Pyuria suggests urinary tract infection.
- pH >6 suggests renal tubular acidosis (type I)
- Urine culture: Evaluation for urinary tract infection
- Serum protein levels: Very low levels imply impaired liver function, severe chronic weight loss, or protein malabsorption.
- Tuberculosis skin test: Possible chronic infection
- Liver function tests: Evaluation for hepatitis, chronic liver disease
Depending on age and clinical findings, other tests to consider include:
- Thyroid function tests
- Sweat test
- Tests for malabsorption (e.g., lactose breath test, stool fat, stool for trypsin)
- Tests for metabolic disease (e.g., plasma ammonia, lactate, serum/urine amino acids, urine organic acids)
- Imaging studies (e.g., CT, MRI, bone scan)
- Immunologic studies
Weight Loss - differencial diagnosis
- Congenital/Anatomic:
- Congenital heart disease
- Pyloric stenosis
- GI malformation (duodenal atresia, annular pancreas, volvulus)
- Short bowel syndrome
- Lymphangiectasia
- Superior mesenteric artery syndrome
- Gastroesophageal reflux
- Immunodeficiency disorders
- Hirschsprung disease
- Infectious:
- UTI
- Tuberculosis
- Stomatitis
- Osteomyelitis
- Human immunodeficiency virus
- Hepatitis
- Parasitic disease
- Abscess, intra-abdominal
- Gastroenteritis
- Pericarditis
- Histoplasmosis
- Acute severe febrile illness (pyelonephritis, pneumonia, septic arthritis)
- Toxic, environmental, drugs:
- Lead poisoning
- Mercury poisoning
- Vitamin A poisoning
- Chronic methylphenidate, dextroamphetamine, or valproic acid use
- Substance abuse, especially amphetamines and crack cocaine
- Trauma:
- Chronic subdural hematomas
- Tumor:
- Diencephalic syndrome
- Leukemia
- Lymphoma
- Pheochromocytoma
- Other neoplasms
- Genetic/Metabolic:
- Diabetes mellitus
- Diabetes insipidus
- Hyperthyroidism
- Cystic fibrosis
- Shwachman syndrome
- Addison disease
- Hypercalcemia
- Congenital adrenal hyperplasia
- Lactose intolerance
- Renal tubular acidosis
- Chronic renal failure
- Hypopituitarism
- Inborn errors of metabolism
- Storage diseases
- Muscular dystrophy
- Lipodystrophy
- Allergic/Inflammatory:
- Inflammatory bowel disease
- Juvenile rheumatoid arthritis
- Systemic lupus erythematosus
- Sarcoidosis
- Pancreatitis
- Hepatitis
- Celiac disease (gluten enteropathy)
- Functional/Miscellaneous:
- Malnutrition
- Child abuse
- Postoperative
- Dieting
- Rumination syndrome
- Depression/Affective disorders
- Anorexia nervosa
- Inability to eat (new orthodontic appliances, loss of teeth, chronic mouth ulcerations)
- Chronic congestive heart failure
- Chronic pulmonary disease
- Chronic renal disease
- Iron deficiency
- Zinc deficiency
- Cerebral palsy
- Postinfectious malabsorption
- Factitious (e.g., scale error)
Emergency care:
- Significant dehydration:
- Abnormal vital signs with orthostasis, decreased urine output, decreased skin turgor, delayed capillary refill (>3 seconds)
- Mandates cardiovascular support (IV hydration) and a more urgent diagnosis (e.g., inborn error of metabolism, obstructive GI disease, congenital adrenal hyperplasia, diabetic ketoacidosis)
- Abnormal mental status, significant lethargy may be seen in:
- Severe dehydration
- Hypoadrenalism
- Hypoxic states
- Toxic ingestions
- Renal or respiratory failure
- Increased intracranial pressure
- Severe electrolyte abnormalities
- Increasing vomiting in the setting of known weight loss in infants:
- High risk for dehydration, hypoglycemia, and electrolyte abnormalities
- Need to evaluate for treatable conditions (e.g., obstructive GI disease, inborn errors of metabolism, congenital adrenal hyperplasia, congenital heart disease) in which a delay is life threatening
- Severe malnutrition (weight loss >20% of ideal body weight):
- High risk for metabolic derangements, including dysrhythmias secondary to electrolyte abnormalities
- Aggressive evaluation is warranted.
Weight Loss - FOLLOW UP
Weight Loss - disposition
Weight Loss - issues for referral
Weight loss is a diagnostic exigency—a cause must be found or the loss self-resolved. If a diagnosis is not uncovered in the setting of continued weight loss, referral to a pediatric diagnostic center is indicated.
Weight Loss - bibliography
Kleinman RE, ed. Pediatric Nutrition Handbook. 5th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2004.- Macdonsal PD, Ross SRM, Frant L, et al. Neonatal weight loss in breast and formula fed infants. Arch Dis Child Fetal Neonal Ed. 2003;88:F472–476.
- Schechter M. Weight loss/failure to thrive. Pediatr Rev. 2000;21:238–239.
Weight Loss - CODES
Weight Loss - icd9
783.21 Loss of weight
Weight Loss - FAQ
- Q: How common is weight loss in the 1st 2 weeks of life?
- A: Formula-fed babies may lose up to 7% of birth weight and breast-fed newborns up to 10% before regaining their birth weight by 2 weeks of age.
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Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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