Case 26: Not Gaining Weight, 9 Week Old

Front 1

How to assess weight gain in the newborn?

Back 1

• most newborns lose some weight immediately after birth, but uncommonly exceeds 10%
  
• 20-30 grams per day during the first 4 months of life
  
• Weight doubles by approximately 4 months for the average infant, although someinfants reach this weight by 3 months.
  

Front 2

What is failure to thrive?

Back 2

Poor weight gain by infants and young children is labeled "lack of physiologic growth anddevelopment," but is commonly called "failure to thrive" (FTT). The term FTT will be used for therest of the discussion.

Front 3

When does FTT occur?

Back 3

• weight below third percentile
  
• weight for height/length falls below third percentile
  
• The rate of weight gain slows compared with previous growth, crossing two or more majorpercentiles on the growth chart in a downward direction.
  

Front 4

Conditions can result in FTT. List some.

Back 4

• Chronic diarrhea or vomiting
  
• CHF
  
• formula allergy
  
• improperly prepared formula
  
• inadequate formula volume
  
• malabsorption
  
• parental neglect
  
• severe gastroesophageal reflux
  

Front 5

Organic FTT

Back 5

Organic FTT is diagnosed when growth failure is causedby an acute or chronic disorder that results in inadequatenutrient intake, malabsorption of nutrients, or increasedenergy requirements.

Front 6

Common causes of organic FTT

Back 6

• Congenital heartdefects
  
• Cystic fibrosis
  
• Developmentaldelay with poorsuck and swallow
  
• Renal tubularacidosis, andMilk proteinallergy
  
• HIV
• Vomiting causedby severegastroesophagealreflux or bowelobstruction.

Front 7

Non organic FTT

Back 7

• poor growth not result of underlying disease or disorder
  
• nearly 90% of FTT are non organic
  
• occassionaly reflects neglect of infant
  
• less commonly psychological basis
  

Front 8

Causes of Non-organic FTT

Back 8

• poverty
  
• poor understanding of feeding techniques
  
• improperly prepared formula
  
• inadequate supply of breast milk
  

Front 9

caloric requirements of infants?

Back 9

100-110 cal/kg/day in first 4 months of life

Front 10

Normal RBC values for infants?

Back 10

The mean value for hemoglobin for healthy full-term 2-month-old infants is 11.2 g/dL (112g/L), an anticipated drop from the mean hemoglobin at birth of 16.5 g/dL (165 g/L).

Front 11

Physiologic anemia?

Back 11

The decrease in hemoglobin occurs because fetal RBCs have a short half-life that leads to a"physiological nadir" for hemoglobin, sometimes also called "physiological anemia."

Front 12

When is the bone marrow stimulated to produce new RBCs?

Back 12

110 g/L at 7-9 weeks

Front 13

Causes of anemia in infants?

Back 13

• iron deficiency
  
• chronic disease
  
• hemolysis
  
• blood loss

Front 14

CF inheritance pattern?

Back 14

autosomal recessive

. For an infant to have the disease, both parentsmust be heterozygote carriers of the mutant allele. Each child of this couple have will have a 25%chance of having CF, a 25% chance of being unaffected, and a 50% chance of being a carrier likehis parents.

Front 15

Genetic counselling for CF?

Back 15

• parents have the chance of having another child with CF in the future
  
• potential for screening parents should be discussed
  
• may benefit from speaking with genetic counselor
  
• determine the CF genotype

Front 16

How to ID individuals with CF?

Back 16

• index of suspicion: steatorrhea, malabsorption, chronic cough
  
• newborn screen
  

Front 17

Who is on the time for children with cystic fibrosis?

Back 17

• pulmonologists
  
• nutritionists
  
• social workers
  
• respiratory and physical therapists
  

Front 18

Questions to ask about feeding in infants?

Back 18

Ask about breast feeding versus bottle feeding and whether the infant has been fed by one orthe other means-or both-since birth.If breastfeeding, how long does the baby feed at a time and does he feed on both breasts?Does his mother have adequate breast milk, and does she eat a healthy diet and drink plentyof fluids?If the baby is bottle-fed, is the formula prepackaged or prepared?How does she prepare the formula and how much water does she add?Has the formula recently been changed?

Front 19

How to help parents/caregivers make informed decisions?

Back 19

• identify concerns
  
• provide adequate information
  
• do not be judgemental
  
• do be impartial
  

Front 20

What is the DDx for organic failure to thrive

Back 20

• CHF
  
• formula allergy
  
• gastroenteritis
  
• hypothyroidism
  
• malabsorption
  

Front 21

CHF

Back 21

CHF is important to consider in any child with FTT.Difficulty feeding and respiratory distress would commonly be described.

Front 22

Formula allergy

Back 22

True milk-protein allergy is difficult to diagnose, but typically causesintestinal blood loss (may be gross or occult).These children may also have fussiness, particularly after feeds andvomiting.

Front 23

Gastroenteritis

Back 23

Gastroenteritis may cause FTT, but is typically associated with bothvomiting and diarrhea and may also be associated with fever and/orbloody stools

Front 24

Hypothyroidism

Back 24

Hypothyroidism may cause FTT in a young infant.Infants with hypothyroidism tend to have poor feeding and constipationrather than eager feeding and increased stools.

Front 25

Malabsorption

Back 25

A history of poor weight gain in the setting of good caloric intake and thepresence of loose stools is concerning for malabsorption.

Front 26

Tools for screening studies for FTT

Back 26

CBC

urinalysis

Bun/cr

Front 27

What is the sweat chloride test?

Back 27

used to diagnose CF

sens: 99%

spec: 90%

false positives can occur

Front 28

Newborn screening for CF?

Back 28

detects immunoreactivetrypsinogen in blood, with confirmatory tests done to make the final diagnosis.

Front 29

When is genetic typing done for CF?

Back 29

f genetic testing is not done as part of the diagnostic workup, most CF experts now recommendgenotyping of patients with CF in order to identify their specific mutations.Although gene therapy for CF is not yet a reality, there are studies currently evaluating not onlygene therapy but also medications that address specific mutations in CF.

Front 30

Managing CF?

Back 30

• multipronged approach:
  
• nutritional management with enzymes and vitamins and extra calories
  
• airway clearance
  
• treatment of airway infections
  

Front 31

Improved outcomes for CF?

Back 31

• not a cure yet
  
• promises for future treatments with genetic modifying meds