Peds Case 26- 9W/o Not Gaining Weight

Front 1

Nml infant weight gain

Back 1

20-30 grams per day during the first 4 months of life
newborn infants lose some weight, but uncommonly exceeds 10% birth weight.
Weight doubles by 4 months (3 for some)
half of the weight gained during first 4 months of life is fat, (fattest healthy human), 25-26% of weight as fat. Formula-fed infants tend to gain weight faster than do breastfed infants because they ingest more calories.

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some causes of low birth weight

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maternal hypertension, diabetes (although many infants of diabetic mothers are large for gestational age), lupus, and maternal malnutrition. Maternal exposure to substances such as certain medications or tobacco, alcohol or illicit drugs can also cause low birth weight and poor weight gain after birth. Fetal conditions leading to low birth weight are also numerous and include genetic disorders and prenatal infections.

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tobacco and alcohol during pregnancy are concerning

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However, Bobby's birth weight and head circumference were appropriate for gestational age, so there is no evidence that his growth in utero was affected by his mother's substance use. Subtle, long-term effects of fetal alcohol exposure may be difficult to detect early in infancy. In many states, use of tobacco and alcohol during pregnancy will trigger screening of the mother and of the newborn’s meconium to detect other substances of abuse

Front 4

failure to thrive

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1. Weight falls below the 3rd percentile.
2. Weight for height/length falls below the 3rd percentile.
OR 3. The rate of weight gain slows compared with previous growth, crossing two or more major percentiles on the growth chart in a downward direction.

“organic”- poor growth is secondary to another underlying medical condition
“non-organic”- no identified underlying medical cause.

90% non-organic and often relate to issues such as lack of proper feeding or lack of access to adequate food.

insufficient intake, excessive losses, or excessive caloric need

Front 5

organic FTT

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growth failure due to an acute or chronic disorder that causes either decreased nutrient intake, malabsorption of nutrients, or increased energy requirements.

congenital heart defects, cystic fibrosis, renal tubular acidosis GERD, milk protein allergy and HIV,

uncommon present with only poor weight gain without other symptoms such as cough, heart murmur, vomiting or diarrhea, recurrent infections, persistent rashes

Front 6

nonorganic FTT

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poor growth without underlying physiologic cause;

Inadequate caloric intake may be due to poverty, poor understanding of feeding techniques, improperly prepared formula, inadequate supply of breast milk or various other issues. Other causes of non-organic FTT may be due to caregiver depression, other mental illness or inadequate parenting skills that lead to inadequate interaction with and social stimulation of the infant, resulting in poor feeding and FTT.

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cow-milk-based formulas:

Soy-protein-isolate formulas include

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Enfamil (Meade Johnson), Good Start (Nestle), and Similac (Ross)

Good Start Soy (Nestle), Isomil (Ross), and Prosobee (Meade Johnson).

One major difference between breast milk and formula is that breastmilk contains less vitamin D than most commercial formulas. Supplementation with vitamin D is recommended in exclusively breast-fed infants or in infants receiving limited amounts of formula

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full-term infants typically need to consume ? in the first 4 months of life

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100-110 Cal/kg/24 hours

consider in an infant with failure to thrive is whether the formula is being mixed appropriately. Formulas come in different forms; some are ready-to-feed; some are powdered and need to be mixed with the appropriate amount of water; and some are liquid but concentrated and need to be mixed with the appropriate amount of water. Improperly prepared formula may be too concentrated or too dilute and result not only in excessive or inadequate calorie intake but also in electrolyte abnormalities (hyponatremia)

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not on the ddx

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Pyloric stenosis, although it may cause FTT, typically presents with projectile vomiting; stools are not greasy. Gastroenteritis may also cause FTT but is typically associated with both vomiting and diarrhea and may also be associated with fever and/or bloody stools. Hypothyroidism may cause FTT in a young infant but infants with hypothyroidism tend to have poor feeding and constipation rather than eager feeding and increased stools

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formula allergy

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bloody stools
also have fussiness, particularly after feeds and vomiting. Poor weight gain as an isolated finding would be unusual

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conditions can result in FTT

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Chronic diarrhea or vomiting
Congestive heart failure (CHF)
Formula allergy
Improperly prepared formula
Inadequate formula volume
Malabsorption
Parental neglect
Severe gastroesophageal reflux

Front 12

FTT b/c CHF

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difficulty feeding and respiratory distress
crackles in the lungs suggestive of pulmonary edema.
liver palpable

Front 13

gastroesophageal reflux or bowel obstruction.

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no vomiting to suggest severe

Front 14

gasteroenteritis

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absence of fever and vomiting, the chronicity of Bobby’s symptoms, and the time course of his poor weight gain do not fit with any acute illness.

has not had profuse watery diarrhea typical of acute gastroenteritis, some infectious etiologies (e.g. Giardia) may have a more indolent, chronic course

Front 15

tests for FTT

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CXR- cardiomeg and pulm infiltrates
BUN/Cr-poor growth may reflect renal failure
CBC and BMP
Fecal Fat analysis or fecal elastase for panc insuff
LTFs- biliary congestion from CF or infxn or other
test for CF used in NBS not valid b/c age
stool reducing sub detect protein malabsorb
fecal occult blood test for milk allergy
ova, parasites in stool
stool culture
UA- renal tubular acidosis, UTI, hematuria
sweat chloride test

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Anemia of Chronic disease

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normocytic, normochromic anemia

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Anemia due to Hemolysis

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drop in the total number of red blood cells and damages the remaining RBCs.
peripheral blood smear to assess RBC morphology

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anemia due to blood loss

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Blood loss will cause a normocytic, normochromic anemia

Front 19

Iron deficiency

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microcytosis along with the low hemoglobin
iron deficiency does not manifest this early in full-term infants unless there is blood loss.
all of Bobby’s formulas have been iron supplemented

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physiological anemia

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hemoglobin @ 2 mos 11.2 g/dL, an anticipated drop from 16.5 g/dL at birth.
decrease b/c fetal RBCs have a short half-life that leads to a “physiological nadir” for hemoglobin, sometimes also called “physiological anemia.”
marrow is only stimulated to produce new RBCs when the hemoglobin reaches its nadir of about 11 g/dL (110 g/L) at 7-9 weeks of age, after which the hemoglobin rises

Front 21

sweat chloride test

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needs to be confirmed on a second test before the diagnosis of CF can be made
known to have 2 CF-causing mutations (on newborn screening), then only 1 abnormal sweat test would have been necessary to make the diagnosis, in light of his symptoms and FTT.

Many states now identify CF by the neonatal screening program that detects immunoreactive trypsinogen in blood, with confirmatory tests done to make the final diagnosis. If genetic testing is not done as part of the diagnostic workup, most CF experts now recommend genotyping 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 only gene therapy but also medications that address specific mutations in CF.

An abnormal sweat test in someone with symptoms consistent with CF is most likely to indicate CF, but there are causes of false positive or false negative sweat tests that need to be considered. The sweat chloride test has a sensitivity of 99%, and specificity near 90%.
False negatives can occur with a specific rare CF mutation;
false positives can occur with a number of metabolic disorders:
adrenal insufficiency and hypothyroidism

>60= abnml

Front 22

CF

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CF is an autosomal recessive disorder
more than 1,500 known mutations of the CFTR associated with CF, but the most common mutation is delta-F508

10-15%, who do not have pancreatic insufficiency, so they don’t present with steatorrhea and malabsorption
present w chronic cough, recurrent bronchitis or sinusitis

one problem: inflammation in the lungs, probably related to the chronic infection but maybe even due to the underlying genetic problem

infertility and he’s found to have congenital absence of the vas deferens

diagnosed through neonatal screening have better nutritional status at the time of diagnosis and may have fewer nutritional, pulmonary, and growth complications throughout life compared to persons diagnosed after the neonatal period
avg age of dx below 12mos (down from 2.9yrs down from 4yrs)

Front 23

NBS CF test

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immunoreactive trypsinogen, IRT, which is usually present in high levels in the blood of newborn infants with CF. However, infants without CF may also have elevated IRT levels, so confirmatory testing is done either by performing a genotype for the most common CF mutations or by repeating the IRT

Front 24

multivitamin for CF

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ADEK
fat soluble vit