Poor Weight Gain - Case 6-7: 18-Month-Old Boy
I. History of Present Illness
An 18-month-old was brought to the emergency department with a chief complaint
of draining ear. In the emergency department, it was noted that he was markedly
wasted. Vital signs included a body temperature below normal; height, weight,
and head circumference were below the 3rd percentile. The heart rate was 40 bpm
with a respiratory rate of 26/minute.
The examination of the ears showed bilateral draining otitis media. There was
loss of hair that was brittle. There were multiple scabs on the body. The
examination was very notable for loss of almost all subcutaneous tissue. Figure
6-3 shows the child at the time of admission. There was no reported weigh loss
or diarrhea. The mother reported no other symptoms.
II. Past Medical History
The child had been born in a healthy condition. The mother was married and
living in a suburban community. The child had grown normally for several
months, but then the mother noted multiple food allergies and placed him on a
restrictive diet. She had not sought regular care for the child but frequently
sought advice from telephone hotlines and calls to multiple physicians
' offices. The child had lost developmental milestones. The mother and father
were both college graduates. There was no smoking or drinking in the house.
Both parents admitted to using marijuana on a regular basis.
II. Physical Examination
T, 35.9°C; RR, 16/min; HR, 40 bpm; BP, 70/40 mm Hg
Weight and height far below 5th percentile; head circumference, 10th percentile
In general, the child was a weak-appearing and cachectic boy with decreased
movement and a weak cry. His hair was stubbled. He had a purulent draining
otitis media. There was no adenopathy. The chest was clear. The heart rate was
bradycardic with weak pulses. The abdomen was scaphoid with decreased bowel
sounds. On the skin, there were multiple marks and scars and hyperpigmented
macules in the diaper area and diffusely. On neurologic examination, responses
were dull, apathetic, and weak. He had decreased muscle mass and muscle tone.
IV. Diagnostic Studies
Laboratory studies were notable for a mild iron deficiency anemia (hemoglobin,
9.6 mg/dL) and mildly decreased serum protein.
V. Course of Illness
The hospital course involved treating the ear infection and starting the child
on nutritional support and iron. He responded with weight gain and improvement
in development. At the end of 2 weeks in the hospital, he had made tremendous
strides in both growth and development. He ate large quantities of food. The
parents underwent psychiatric testing and were determined to be unsuitable
caretakers. The child recovered completely and was discharged to a foster home
(Fig. 6-4).
Discussion: Case 6-7
I. Differential Diagnosis
The severity of this child's condition prompted the consideration of a wide differential diagnosis. The
parent
's economic status and educational level at first prompted the medical care team
to eliminate psychosocial causes. Yet, the child
's response to supportive care and feeding and the normal laboratory pattern that
he demonstrated revealed a nonorganic cause for his life-threatening condition.
II. Diagnosis
The final diagnosis was weight loss and developmental repression due to
psychosocial causes.
The diet that the mother selected for the child was too restrictive in content
and calories. Her presenting complaint missed the obvious wasting and was a
clue to her lack of perception and parenting ability.
III. Incidence and Epidemiology
The true incidence of psychosocial FTT is not known. Many case series of
children with FTT show that 40% to 80% of cases are due to psychosocial causes
or a combination of psychosocial and medical causes (so-called mixed FTT). The
epidemiology is varied and can result from postpartum depression, lack of
knowledge about parenting, or more overt child abuse and willful starvation. It
is difficult to sort through the motivation of the parents, yet the results in
the child are obvious and disturbing.
IV. Clinical Presentation
Clinical presentations are varied, from children who have minor falling off on
their growth parameters to cases of death by starvation. Serial measures of
length or height, weight, and head circumference are helpful in sorting through
the causes and in differentiating psychosocial and medical causes.
V. Diagnostic Approaches
Diagnostic approach is best directed by the signs and symptoms the child
manifests. Without special symptoms, it is best to feed the child in a
controlled setting and monitor the weight gain. There is no single battery of
laboratory tests to be recommended. Some tests that may be helpful are the
complete blood count (iron deficiency anemia), urinalysis (urinary tract
infection, renal tubular acidosis), and the purified protein derivative (PPD)
test for tuberculosis. HIV infection may also be a cause for FTT. Skeletal
survey for trauma may be indicated if there is suspicion of abuse.
VI. Treatment
Treatment for nonorganic FTT requires close follow-up and a multidisciplinary
approach to meet the needs of the child and the family. In some cases, the
child must be removed from the care of the parents until a system of care and
follow-up can be proposed. In this case, a foster home was used initially, and
then the child was returned home under close (weekly) supervision.
Subsequently, a physical abuse episode resulted in long-term removal of the
child. In most cases, the nutritional recovery time equals the duration of the
organic deprivation.
VII. References
1. Ludwig S. Failure-to-thrive and starvation. In: Ludwig S, Kornberg A, eds. Child abuse and neglect: a medical reference, 2nd ed. New York: Churchill-Livingstone, 1992.
2. Altemeier WA, O'Connor SM, Sherrod KB, et al. Prospective study of antecedents for nonorganic
failure-to-thrive.
J Pediatr 1985;106:360.
3. Sturm L, Drotar D. Prediction of weight for height following intervention in
three-year-old children with early histories of nonorganic failure-to-thrive.
Child Abuse 1989;13:19.
4. Frank DA, Drotar D, Cook J, et al. Failure to thrive. In: Reece R, Ludwig S,
eds.
Child abuse: medical diagnosis and management, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2001.
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.
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