Poor Weight Gain - Case 6-5: 3-Month-Old Girl
I. History of Present Illness
A 3-month old girl was referred by her pediatrician to the emergency department
because of FTT. She had had problems gaining weight since 1 to 2 months of age
and had been monitored weekly for weight checks with poor weight gain. She was
initially breast-fed but had poor latching-on and was changed to Enfamil
formula with iron, then Enfamil without iron, Lactofree, ProSobee, and now is
on Similac with iron. The family had tried thickening feeds with cereal and
bananas with no improvement. The child was taking 4 ounces per feeding and was
burped after every 2 ounces. Intake was 28 ounces per day. She typically spit
and vomited, sometimes forcefully, 1 to 2 ounces per feed. The emesis was
nonbloody, nonbilious, and occasionally projectile. The emesis had become worse
over the last month. There had been no diarrhea. For the last 3 days, she had
been less active than usual and had glassy-appearing eyes. Urine output had
decreased; on the day of presentation, she had had only 2 wet diapers, compared
with her usual 7 to 10 per day.
II. Past Medical History
The infant was born to a 16-year-old mother. The mother had prenatal care
beginning in the second month of pregnancy. The child was born at term with a
weight of 3,440 g. There were no postnatal complications, and she was
discharged home at 39 hours of age. Development had been normal. She rolled
from front to back at 6 weeks of life. She received no medications. Her
immunizations were current. The family history was unremarkable.
III. Physical Examination
T, 37°C; RR, 18/min; HR, 129 bpm; BP, 68/41 mm Hg
Weight, 3.89 kg (50th percentile for a 1-month-old child)
On examination, the child was crying but consolable. She had markedly decreased
subcutaneous fat. The anterior fontanel was sunken. The pupils were reactive to
light. There was no nasal discharge. The heart and lungs were normal to
auscultation. The abdomen was scaphoid with visible peristaltic waves. The
spleen tip was palpable below the left costal margin. The extremities were
slightly cool, with capillary refill times of 2 to 3 seconds. The neurologic
examination was normal.
IV. Diagnostic Studies
Complete blood count revealed the following: 8,800 WBCs/mm3 (1% band forms, 59% segmented neutrophils, 30% lymphocytes, and 10% monocytes);
hemoglobin, 12.9 mg/dL; and 195,000 platelets/mm
3. Serum electrolyte analysis revealed the following: sodium, 129 mEq/L;
chloride, 65 mEq/L; bicarbonate, 53 mEq/L; blood urea nitrogen, 48 mg/dL; and
creatinine, 1.4 mg/dL. Serum transaminases were normal. Other studies included
a cholesterol of 206 mg/dL and triglycerides of 313 mg/dL.
V. Course of Illness
In the emergency department, the patient received approximately 40 mL/kg of
normal saline. She was admitted to the intensive care unit due to rapid but
periodic breathing. An abdominal radiograph (Fig. 6-1) revealed a markedly
distended stomach with a paucity of bowel gas pattern beyond the stomach.
Abdominal ultrasound (Fig. 6-2) revealed the diagnosis.
Discussion: Case 6-5
I. Differential Diagnosis
The differential diagnosis in this case included some form of upper bowel
obstruction. There was a marked hypochloremic alkalosis to support this kind of
loss, along with the associated history. Severe gastroesophageal reflux,
gastric outlet obstruction, pyloric stenosis, or some kind of duodenal anomaly
(e.g., duplication) was possible. The upper gastrointestinal radiograph
delineated the lesion of pyloric stenosis. The electrolyte disturbance was
characteristic of an upper bowel atresia with loss of sodium, chloride, and
hydrogen ion.
II. Diagnosis Pyloric Stenosis
The abdominal ultrasound study showed a thickened and elongated pylorus, with a
maximal muscle length measuring 19 mm (Fig. 6-2). The maximal muscle thickness
was 5 mm. The gastric antrum was also imaged, and there was evidence of
significant fluid and debris from the prior oral feeding.
These findings were consistent with the diagnosis of pyloric stenosis. Once the patient's metabolic derangement was corrected, she was taken to the operating room for a
pyloromyotomy. The postoperative course was uneventful. This case was unusual
in terms of the late onset of pyloric stenosis; most cases are identified in
the first 3 to 6 weeks of life.
III. Incidence and Epidemiology
Pyloric stenosis occurs in 1 of every 200 male infants and in 1 of every 1,000
females. The mode of inheritance is polygenic and modified by sex. The disorder
is associated with smaller family size and higher socioeconomic status. In the
United States, it is more common among African-Americans and Asian-Americans
than other groups.
IV. Clinical Presentation
The clinical presentation is based on vomiting (often projectile in nature),
failure to gain weight, and constipation. There are no other associated
symptoms. On examination, the hypertrophied pyloric muscle (
“olive”) is occasionally palpated in the right upper quadrant.
V. Diagnostic Approach
The palpation of the pyloric olive is often difficult and examiner dependent.
Serum electrolytes. Electrolytes reveal a hypochloremic metabolic alkalosis.
Abdominal ultrasonography. Ultrasound studies typically reveal thickening of the pyloric muscle wall. For a
broader differential diagnosis, an upper gastrointestinal barium study should
be considered.
VI. Treatment
The treatment is a simple pyloromyotomy, which opens the pyloric channel and
allows the passage of food into the small bowel. The symptoms resolve within a
few days after surgery. There are no long-term complications, and patients may
be discharged postoperatively when they are able to tolerate feeding.
VII. References
1. Garcia VF, Randolph JG. Pyloric stenosis: diagnosis and management. Pediatr Rev 1990;11:292–296.
2. Letton RW Jr. Pyloric stenosis. Pediatr Ann 2001;30:745–750.
3. Zenn MR, Redo SF. Hypertrophic pyloric stenosis in the newborn. J Pediatr Surg 1993;28:1577–1578.
4. Murtagh K, Perry P, Corlett M, et al. Infantile hypertrophic pyloric
stenosis.
Dig Dis 1992;10:190–198.
5. Spicer RD. Infantile hypertrophic pyloric stenosis: a review. Br J Surg 1982;69:128–135.
Pictures
Book Source Details
- Book Title: Pediatric Complaints and Diagnostic Dilemmas
- Author(s): Samir S Shah MD; Stephen Ludwig MD
- Year of Publication: 2003
- Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2008 Williams & Wilkins.
More About Causes of Weight gain
» Next page: Poor Weight Gain - Case 6-6: 21-Month-Old Boy (Pediatric Complaints and Diagnostic Dilemmas)
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