Failure to thrive - an overlooked manifestation of KMT2B-related dystonia: a case presentation

Background

KMT2B-related dystonia is a recently described form of childhood onset dystonia that may improve with deep brain stimulation. Prior reports have focused on neurologic features including prominent bulbar involvement without detailing general health consequences that may result from orolingual dysfunction. We describe a family with novel KMT2B mutation with several members with failure to thrive to highlight this non-neurologic, but consequential impact of mutation in this gene.

Case presentation

We present a case of a 15-year old female who was admitted and evaluated for failure to thrive. On exam, she had severe speech dysfluency, limited ability to protrude the tongue, and generalized dystonia involving the oromandibular region, right upper and left lower extremity with left foot inversion contracture. The proband and her parents underwent whole genome sequencing. A previously undescribed variant, c.4960 T > C (p.Cys1654Arg), was identified in the KMT2B gene in the proband and mother, and this variant was subsequently confirmed in two maternal cousins, one with failure to thrive. Literature review identified frequent reports of prominent bulbar involvement but failure to thrive is rarely mentioned.

Conclusion

Failure to thrive is a common pediatric clinical condition that has consequences for growth and development. In the presence of an abnormal neurologic exam, a search for a specific underlying genetic etiology should be pursued. With this case series, we highlight an unusual potentially treatable cause of failure to thrive, reinforce the importance of precise molecular diagnosis for patients with failure to thrive and an abnormal neurologic exam, and underscore the importance of cascade screening of family members.

Effect of nutritional supplement formula on catch-up growth in young children with nonorganic faltering growth: a prospective multicenter study

BACKGROUND/OBJECTIVES

Inadequate nutrition in infants and young children affects physical growth and neurocognitive development. Therefore, early nutritional intervention is important to promote catch-up growth in young children with faltering growth. The aim of this study was to evaluate the effect of nutritional supplementation with a pediatric concentrated and balanced nutritional supplement formula on promoting growth and improving nutritional status in children with nonorganic faltering growth.

SUBJECTS/METHODS

Children aged 12–36 months whose body weight-for-age was < 5^th percentile on the Korean Growth Charts were enrolled. Children born premature or having organic diseases were excluded. Children were instructed to consume 400 mL of formula per day in addition to their regular diet for 6 months. Pediatricians and dietitians educated the parents and examined the subjects every 2 months. Anthropometric parameters were measured at baseline and at 2, 4, and 6 months, and laboratory tests were done at baseline and 6 months. The good consumption group included children who consumed ≥ 60% of the recommended dose of formula.

RESULTS

Total 82 children completed the 6-month intervention. At baseline, there were no significant differences in all variables between the good consumption and poor consumption groups. Weight and weight z-scores were significantly improved in the good consumption group compared to the poor consumption group at the end of the intervention (P = 0.009, respectively). The good consumption group showed a significant trend for gaining weight (P < 0.05) and weight z-score (P < 0.05) compared to the poor consumption group during 6 months of formula intake. The concentration of blood urea nitrogen was significantly increased in the good consumption group (P = 0.001).

CONCLUSIONS

Nutritional supplementation with a concentrated and balanced pediatric nutritional formula along with dietary education might be an effective approach to promote catch-up growth in children with nonorganic faltering growth.

Feeding difficulty and gastrostomy tube placement in infants with Down syndrome

The objectives of this study were to determine if any specific clinical signs, symptoms, or comorbidities could reliably predict underlying feeding difficulty and need for further evaluation (i.e., video swallow study, VSS) in infants with Down syndrome, to establish the prevalence of gastrostomy tube placement (G-tube), and to determine if any clinical signs, symptoms, or comorbidities correlated with a higher risk for needing placement of a G-tube. An electronic medical record retrospective chart review of 73 children with Down syndrome born between January 2013 and March 2017 and seen in Nationwide Children's Hospital's multidisciplinary Down Syndrome Clinic included demographic information, medical history, and results of studies and specialist evaluations. Descriptive statistics were utilized to summarize the data. Comparisons were performed to identify factors which differed between feeding difficulty vs. no feeding difficulty and G-tube placement vs. no G-tube placement. "Feeding difficulty" was the only feeding term established by the AAP guidelines which was consistently noted in charts of children with feeding abnormalities. Infants with feeding difficulty had increased use of medical services and more abnormalities on specialist evaluations and studies. Congenital heart disease, cardiothoracic surgery, obstructive sleep apnea, and hypothyroidism did not differ significantly between the groups assessed. Our cohort had a prevalence of 13.7% for requiring G-tube placement in their first year of life.Conclusion: The currently established clinical tools for determining which patients may benefit from radiographic evaluation lack sufficient sensitivity to detect all individuals with feeding difficulty. Due to the high prevalence of abnormal VSS results and high rate of G-tube placement, universal radiographic screening for individuals with Down syndrome could be considered, even in the absence of obvious clinical signs or symptoms. However, determining how to balance this with cost, availability, and radiation exposure may be difficult.What is Known: • Feeding difficulty in children with Down syndrome can lead to significantly increased morbidity, such as poor weight gain, failure to thrive, aspiration, persistent respiratory symptoms, andrecurrent pneumonia. • The AAP has established a clinical tool regarding which objective signs and symptoms should lead to a radiographic swallowing assessment within their Health Supervision for Children with Down Syndrome Clinical Report.What is New: • A comprehensive assessment of clinical signs, symptoms, and common comorbidities in infants with Down syndrome has not previously been correlated with presence of feeding difficulty nor necessity for gastrostomy tube placement, including whether or not the terms used in the AAP guidelines encompass the sensitivity required to detect all infants with feeding difficulty. • The prevalence of gastrostomy tube placement in children with Down syndrome has not previously been established.

Safety and outcome of gastrostomy tube placement in patients with Loeys-Dietz syndrome

Background

Loeys-Dietz syndrome (LDS) is a systemic connective tissue disease (CTD) associated with a predisposition for intestinal inflammation, food allergy, and failure to thrive, often necessitating nutritional supplementation via gastrostomy tube. Poor wound healing has also been observed in in some patients with CTD, potentially increasing the risk of surgical interventions. We undertook to determine the safety and efficacy of gastrostomy tube placement in this population.

Methods

We performed a retrospective cohort study of 10 LDS patients who had a total of 12 gastrostomy tubes placed.

Results

No procedural complications occurred, although one patient developed buried bumper syndrome in the near post-procedural time period and one patient had a small abscess at a surgical stitch. Most patients exhibited improvements in growth, with a median immediate improvement in BMI Z-score of 0.2 per month following the institution of gastrostomy tube feedings. Those with uncontrolled inflammation due to inflammatory bowel disease or eosinophilic gastrointestinal disease showed the least benefit and in some cases failed to demonstrate significant weight gain despite nutritional supplementation.

Conclusions

Gastrostomy tube placement (surgical or endoscopic) is a generally safe and a reasonable therapeutic option for patients with LDS despite their underlying CTD.

Heiner Syndrome: An uncommon cause of failure to thrive

Heiner syndrome (HS) is a rare hypersensitivity reaction of an infant or young child to cow milk proteins. It is a disease characterised by failure to thrive, respiratory symptoms like cough, dyspnoea, wheeze and rhinitis with accompanying chest infiltrates on chest radiograph; gastrointestinal symptoms like vomiting, diarrhoea; and anaemia. The non-specific nature of the disease can result in delayed diagnosis and treatment and central to the condition is hypersensitivity to cow milk proteins.

Several cases have been reported worldwide but there has been no report of this condition in Africa.

We highlight the case of a sixteen week old child seen in our facility with features typical of Heiner syndrome. Clinicians should have a high index of suspicion for this condition especially in children predominantly on infant formula.

The "Silk Road": A novel method for inserting transpyloric feeding tubes in low resource settings

INTRODUCTION

Transpyloric tube (TPT) feeding is used in a multitude of conditions including gastroesophageal reflux disease. We here describe a new simple method to insert TPTs.

METHODS

6 French feeding tube is premeasured nose to xiphisternum, and then another 7cm of length is added and 3-5 silk (4-0) ties are applied to the end of the tube spaced 0.5-1cm apart. The knots are placed in different radial directions, and multiple throws are placed on each knot so as to add bulkiness. The tube is then inserted transnasally to the premeasured length and secured. The child is given a single dose of metoclopramide and placed on his right side for 4h. A plain abdominal x-ray is then performed to confirm adequate TP placement. Following correct placement the patient is tube fed with small volumes every 15-20min. Descriptive data was prospectively collected.

RESULTS

34 patients were recruited, median age 3.5months. All presented with vomiting, and 26 had failure to thrive. 24had successful TP tube placement from the first attempt, 6 from the second attempt, 2 on third attempt, and in 2 placement was unsuccessful. In 28 patients vomiting almost stopped completely. 9 patients had fundoplication, and 1 had gastrostomy placement. 3 patients died during the study because of unknown reasons.

CONCLUSION

The silk tie technique is a safe and simple way to treat persistent vomiting and may prove useful in low resourced environments.

LEVEL OF EVIDENCE

IV.

The diagnosis "failure to thrive" and its impact on the care of hospitalized older adults: a matched case-control study

BACKGROUND

"Failure to thrive" and associated diagnoses are non-specific terms applied to older adults when there is lack of diagnostic clarity and imply an absence of medical acuity. We investigated the effect of such admission diagnoses on delivery of patient care in a cohort of older adults admitted to a tertiary care teaching hospital.

METHODS

Retrospective matched cohort study conducted at a tertiary care hospital in Vancouver, BC. Cases identified were adults aged ≥65 years admitted to acute medical wards with an admission diagnosis of "failure to thrive", "FTT", "failure to cope", or "FTC", between January 1, 2016 and November 1, 2017 (n = 60, median age 80 years). Age-matched controls met the same inclusion criteria with admission diagnoses other than those of interest (n = 60, median age 79 years).

RESULTS

The primary outcome was time to admission, measured from time points in the emergency room that spanned from triage to completion of admission orders. Secondary outcomes were concordance of admission and discharge diagnoses and length of stay in hospital. The total time from triage to admission for older adults admitted with FTT and associated diagnoses was 10 h 40 min, compared to 6 h 58 min for controls (p = .02). Concordance of admission and discharge diagnoses was only 12% for the "failure to thrive" cohort, and 95% for controls. Notably, 88% of the "failure to thrive" cohort had an acute medical diagnosis at the time of discharge. Patients in this cohort stayed 18.3 days in hospital compared to 10.2 days (p = .001).

CONCLUSIONS

Patients with an admission diagnosis of FTT or other associated diagnoses had significant delays in care when presenting to the emergency room, despite often having acute medical conditions on presentation. The use of this non-specific label can lead to premature diagnostic closure and should be avoided in clinical practice.

In-depth phenotyping reveals common and novel disease symptoms in a hemizygous knock-in mouse model (Mut-ko/ki) of mut-type methylmalonic aciduria

Isolated methylmalonic aciduria (MMAuria) is primarily caused by deficiency of methylmalonyl-CoA mutase (MMUT or MUT). Biochemically, MUT deficiency results in the accumulation of methylmalonic acid (MMA), propionyl-carnitine (C3) and other metabolites. Patients often exhibit lethargy, failure to thrive and metabolic decompensation leading to coma or even death, with kidney and neurological impairment frequently identified in the long-term. Here, we report a hemizygous mouse model which combines a knock-in (ki) missense allele of Mut with a knock-out (ko) allele (Mut-ko/ki mice) that was fed a 51%-protein diet from day 12 of life, constituting a bespoke model of MMAuria. Under this diet, mutant mice developed a pronounced metabolic phenotype characterized by drastically increased blood levels of MMA and C3 compared to their littermate controls (Mut-ki/wt). With this bespoke mouse model, we performed a standardized phenotypic screen to assess the whole-body impairments associated with this strong metabolic condition. We found that Mut-ko/ki mice show common clinical manifestations of MMAuria, including pronounced failure to thrive, indications of mild neurological and kidney dysfunction, and degenerative morphological changes in the liver, along with less well described symptoms such as cardiovascular and hematological abnormalities. The analyses also reveal so far unknown disease characteristics, including low bone mineral density, anxiety-related behaviour and ovarian atrophy. This first phenotypic screening of a MMAuria mouse model confirms its relevance to human disease, reveals new alterations associated with MUT deficiency, and suggests a series of quantifiable readouts that can be used to evaluate potential treatment strategies.

A combination of two novel VARS2 variants causes a mitochondrial disorder associated with failure to thrive and pulmonary hypertension

The VARS2 gene encodes a mitochondrial valyl-transfer RNA synthetase which is used in mitochondrial translation. To date, several patients with VARS2 pathogenic variants have been described in the literature. These patients have features of lactic acidosis with encephalomyopathy. We present a case of an infant with lactic acidosis, failure to thrive, and severe primary pulmonary hypertension who was found to be a compound heterozygote for two novel VARS2 variants (c.1940C>T, p.(Thr647Met) and c.2318G>A, p.(Arg773Gln)). The patient was treated with vitamin supplements and a carbohydrate-restricted diet. The lactic acidosis and failure to thrive resolved, and he showed good growth and development. Functional studies and molecular analysis employed a yeast model system and the VAS1 gene (yeast homolog of VARS2). VAS1 genes harboring either one of two mutations corresponding to the two novel variants in the VARS2 gene, exhibited partially reduced function in haploid yeast strains. A combination of both VAS1 variant alleles in a diploid yeast cell exhibited a more significant decrease in oxidative metabolism-dependent growth and in the oxygen consumption rate (reminiscent of the patient who carries two mutant VARS2 alleles). Our results demonstrate the pathogenicity of the biallellic novel VARS2 variants. KEY MESSAGES: • A case of an infant who is a compound heterozygote for two novel VARS2 variants. • This infant displayed lactic acidosis, failure to thrive, and pulmonary hypertension. • Treatment of the patient with a carbohydrate-restricted diet resulted in good growth and development. • Studies with the homologous yeast VAS1 gene showed reduced function of corresponding single mutant in haploid yeast strains. • A combination of both VAS1 variant alleles in diploid yeast exhibited a more significant decrease in function, thereby confirming the pathogenicity of the biallellic novel VARS2 variants.

Congenital diarrhea in a newborn infant: A case report

BACKGROUND

Microvillus inclusion disease (MVID) is a rare autosomal recessive cause of severe congenital diarrhea with significant morbidity and mortality. Definitive treatment involves bowel transplant. The diagnosis of this condition can be challenging and a few genetic panels are available for the identification of the most common mutations. We present the case of an infant with MVID due to a mutation not reported in the literature before.

CASE SUMMARY

We report the case of an infant transferred to our institution with severe diarrhea of unknown etiology, failure to thrive, and significant metabolic derangements. An extensive work-up including stool studies for common gastrointestinal pathogens, abdominal ultrasound, esophagogastroduodenoscopy with duodenal biopsy and flexible sigmoidoscopy failed to reveal a diagnosis. Multiple dietary and formula regimens were introduced but all resulted in voluminous diarrhea. She remained on total parenteral nutrition (TPN) for the duration of her hospital stay. Genetic testing was done and she was subsequently found to have a novel mutation in the MYO5B gene [homozygous mutation for MYO5B c.1462del, p. (Ile488Leufs*93)] giving us the diagnosis of MVID. She remains on TPN while awaiting bowel transplant at the time of the compilation of this case report.

CONCLUSION

We report a novel mutation involved in MVID and highlight the importance of considering this disease when faced with a newborn presenting with life threatening diarrhea. At the time of this publication, 232 allelic variations of this gene (MIM#606540) exist in National Center for Biotechnology Information's database. Our patient's mutation has not been reported in literature as a cause of MVID.

The use of recombinant human growth hormone in patients with Mucopolysaccharidoses and growth hormone deficiency: a case series

BACKGROUND

The treatment with recombinant human growth hormone in patients affected by Mucopolysaccharidoses (MPS) is considered whenever a concurrent diagnosis of growth hormone deficiency is demonstrated. The short- and long-term effects of recombinant human growth hormone in this selected cohort is still debated, given the natural progression of disease-related skeletal malformations and the paucity of treated patients reported in literature. The presented case series provides detailed information about the response to recombinant growth hormone in MPS patients diagnosed with growth hormone deficiency.

CASES PRESENTATION

The growth patterns of 4 MPS female patients (current age: 11.7-14.3 years) treated with recombinant human growth hormone due to growth hormone deficiency have been retrospectively analyzed. Two patients, diagnosed with MPS IH, had undergone haematopoietic stem cell transplantation at an early age; the remaining two patients were affected by MPS IV and VI and were treated with enzyme replacement therapy. 4/4 patients presented with a progressive growth deceleration before the diagnosis of growth hormone deficiency was confirmed. This trend was initially reverted by a remarkable increase in height velocity after the start of recombinant growth hormone. We recorded an average increase in height velocity z-score of + 4.23 ± 2.9 and + 4.55 ± 0.96 respectively after 6 and 12 months of treatment. After the first 12-24 months, growth showed a deceleration in all the patients. While in a girl with MPS IH recombinant human growth hormone was discontinued due to a lack in clinical efficacy, 3/4 patients grew at a stable pace, tracking the height centile achieved after the cited initial increase in height velocity. Furthermore, mineral bone density assessed via bone densitometry, showed a remarkable increase in the two patients who were tested before and after starting treatment.

CONCLUSIONS

Recombinant human growth hormone appears to have effectively reverted the growth deceleration experienced by MPS patients diagnosed with growth hormone deficiency, at least during the first 12-24 months of treatment.

Myxedema Coma due to Hashimoto Thyroiditis: A Rare but Real Presentation of Failure to Thrive in Infancy

BACKGROUND

Hashimoto thyroiditis (HT) is uncommon in infancy, and myxedema coma (MC) is even less common. While prior reports have documented these entities separately, to our knowledge, MC in combination with HT has not been reported before in this age group.

METHODS/RESULTS

A 10-month-old female presented with ptosis, lethargy, dysphagia, and failure to thrive (FTT). She developed hypotension, bradycardia, hypothermia, and apnea requiring intubation. Initial thyroid-stimulating hormone was 422 μIU/mL, and free thyroxine was < 0.5 ng/dL, despite the presence of a normal thyroid newborn screen (NBS). Of note, sepsis workup was unremarkable. With the diagnosis of MC, treatment with intravenous levothyroxine was initiated, although after hydrocortisone administration to avert the possibility of an adrenal crisis, despite a random cortisol of 16.4 μg/dL. Based on positive thyroid antibodies suggesting HT, autoimmune workup later revealed positive acetylcholinesterase antibodies consistent with a diagnosis of ocular myasthenia gravis.

CONCLUSION

MC may be a cause of altered mental status in infancy and may simultaneously be associated with FTT on presentation. With the presence of a normal thyroid NBS, autoimmunity should be entertained as the etiology of profound hypothyroidism, as positive thyroid antibodies may prompt an exploration for coexisting diseases which may explain other presenting features.

Delay in Growth in Adolescents: Clinical Validation of a Proposed Nursing Diagnosis

PURPOSE

This study aims to analyse the accuracy of clinical indicators of the proposed diagnosis of delayed growth in school-aged adolescents.

DESIGN AND METHODS

This is a diagnostic accuracy study of 385 adolescents in public schools from July to September 2017 that aimed to assess the accuracy of clinical indicators of the proposed nursing diagnosis of delayed growth; the sensitivity and specificity values were calculated using latent class analysis.

RESULTS

Growth velocity less than expected was associated with sensitivity and specificity. The clinical indicator short stature for age and sex showed sensitivity. Low weight for age and sex, stature below genetic target and delayed sexual maturation were specific indicators.

CONCLUSION

In a sample of adolescents in public schools in northeastern Brazil, a set of five clinical indicators best indicated delayed growth in adolescents. Two clinical indicators showed sensitivity, and four clinical indicators showed specificity.

PRACTICE IMPLICATIONS

This study contributes to refining the diagnostic proposition of delayed growth in adolescents. Accurate measures for nursing diagnoses can help paediatric nurse practitioners confirm or exclude this diagnosis in adolescents with a similar profile.

Cachexia and advanced dementia

Cachexia is a complex metabolic process that is associated with several end-stage organ diseases. It is known to be also associated with advanced dementia, although the pathophysiologic mechanisms are still largely unknown. The present narrative review is aimed at presenting recent insights concerning the pathophysiology of weight loss and wasting syndrome in dementia, the putative mechanisms involved in the dysregulation of energy balance, and the interplay among the chronic clinical conditions of sarcopenia, malnutrition, and frailty in the elderly. We discuss the clinical implications of these new insights, with particular attention to the challenging question of nutritional needs in advanced dementia and the utility of tube feeding in order to optimize the management of end-stage dementia.

Micronutrients Are Not Deficient in Children with Nonorganic Failure to Thrive

PURPOSE

Inadequate calorie intake is one of the most important causes of nonorganic failure to thrive (NOFTT) and is thought to lead to multiple micronutrient deficiencies. However, there have been few studies on NOFTT and micronutrients. The aim of this study was to evaluate the micronutrient status of children with NOFTT.

METHODS

We conducted a retrospective cohort study in 161 children (106 with NOFTT and 55 health controls) at a single institution. Data on weight for age, height for age, body mass index, and biochemical parameters, indicating the children's nutritional and micronutrient status were reviewed via electronic medical records, and the two groups were compared.

RESULTS

Except inorganic phosphate levels, no statistically significant differences were seen in the laboratory findings indicating the children's nutritional and micronutrient status; notably, the inorganic phosphate levels were within the normal range in both groups. We then compared the severe NOFTT (weight for age below the first percentile) and control groups; however, no statistically significant differences were seen for any of the measured parameters.

CONCLUSION

Most children with NOFTT in this study had normal micronutrient levels and other laboratory findings. Therefore, element deficiencies should not be considered a natural consequence of NOFTT or in healthy children. Close monitoring and additional evaluations are needed.

Bartter Syndrome and Gitelman Syndrome

Bartter and Gitelman syndromes are conditions characterized by renal salt-wasting. Clinical presentations range from severe antenatal disease to asymptomatic with incidental diagnosis. Hypokalemic hypochloremic metabolic alkalosis is the common feature. Bartter variants may be associated with polyuria and weakness. Gitelman syndrome is often subtle, and typically diagnosed later life with incidental hypokalemia and hypomagnesemia. Treatment may involve fluid and electrolyte replenishment, prostaglandin inhibition, and renin-angiotensin-aldosterone system axis disruption. Investigators have identified causative mutations but genotypic-phenotypic correlations are still being characterized. Collaborative registries will allow improved classification schema and development of effective treatments.

Inherited selective cobalamin malabsorption in Komondor dogs associated with a CUBN splice site variant

BACKGROUND

Three Komondor dogs in a small family and 3 sporadic cases exhibited a constellation of signs that included juvenile-onset of failure-to-thrive, inappetence, vomiting and/or diarrhea, and weakness. In each we documented dyshematopoiesis, increased anion gap, methylmalonic acidemia/-uria, and serum cobalamin deficiency. Urine protein electrophoresis demonstrated excretion of cubam ligands. All clinical signs and metabolic abnormalities, except proteinuria, were reversed by regular parenteral cobalamin administration. The pattern of occurrence and findings in the disorder suggested an autosomal recessive inheritance of cobalamin malabsorption with proteinuria, a condition in humans called Imerslund-Gräsbeck syndrome. The purpose of this study was to determine the molecular cause of this disorder in Komondors.

RESULTS

Whole genome sequencing of two affected Komondor dogs of unknown relatedness and one parent and a clinically-normal littermate of an affected dog revealed a pathogenic single-base change in the CUBN intron 55 splice donor consensus sequence (NM_001003148.1: c.8746 + 1G > A) that was homozygous in affected dogs and heterozygous in the unaffected parents. Alleles of the variant co-segregated with alleles of the disease locus in the entire family and all more distantly-related sporadic cases. A population study using a simple allele-specific DNA test indicated mutant allele frequencies of 8.3 and 4.5% among North American and Hungarian Komondors, respectively.

CONCLUSIONS

DNA testing can be used diagnostically in Komondors when clinical signs are suggestive of cobalamin deficiency or to inform Komondor breeders prospectively and prevent occurrence of future affected dogs. This represents the third cubilin variant causing inherited selective cobalamin malabsorption in a large animal ortholog of human Imerslund-Gräsbeck syndrome.

Aspiration and Dysphagia in the Neonatal Patient

Dysphagia and aspiration are commonly encountered problems in the neonatal population. It is often multifactorial in nature and management should be tailored to the individual patient. Multiple causes should be considered, including anatomic abnormalities, neurologic/developmental delay, cardiopulmonary disease/infection, and gastroesophageal reflux disease, in addition to those cases where a definitive reason may not be identified. Management should be multidisciplinary in nature and surgical intervention may be indicated in certain populations of patients. Here, we discuss the presentation, workup, and management of the neonatal patient with dysphagia and aspiration.

LHX3 deficiency presenting in the United States with severe developmental delay in a child of Syrian refugee parents

In this case report, we present a novel mutation in Lim-homeodomain (LIM-HD) transcription factor, LHX3, manifesting as combined pituitary hormone deficiency (CPHD). This female patient was originally diagnosed in Egypt during infancy with Diamond Blackfan Anemia (DBA) requiring several blood transfusions. Around 10 months of age, she was diagnosed and treated for central hypothyroidism. It was not until she came to the United States around two-and-a-half years of age that she was diagnosed and treated for growth hormone deficiency. Her response to growth hormone replacement on linear growth and muscle tone were impressive. She still suffers from severe global development delay likely due to delay in treatment of congenital central hypothyroidism followed by poor access to reliable thyroid medications. Her diagnosis of DBA was not confirmed after genetic testing in the United States and her hemoglobin normalized with hormone replacement therapies. We will review the patient's clinical course as well as a review of LHX3 mutations and the associated phenotype. Learning points: Describe an unusual presentation of undertreated pituitary hormone deficiencies in early life Combined pituitary hormone deficiency due to a novel mutation in pituitary transcription factor, LHX3 Describe the clinical phenotype of combined pituitary hormone deficiency due to LHX3 mutations.

Congenital pyloric atresia - nine new cases: Single-center experience of the long-term follow-up and the lessons learnt over a decade

BACKGROUND

Congenital pyloric atresia (CPA) is a rare anomaly with an incidence of 1 in 100,000 live births. Depending on the type of anomaly patients can either present in the neonatal period or later in life with subtle nonspecific signs and symptoms. We present our institute's experience in handling these cases over the last decade and highlight lessons learnt.

MATERIALS AND METHODS

We retrospectively reviewed records of patients diagnosed with CPA and managed at our centre between Jan 2006 to June 2016. We looked into the period of gestation, birth weight, gender, age at onset of symptoms, age at presentation to the hospital, symptoms, investigations, associated anomalies, management and outcomes and follow up periods.

RESULTS

Nine patients were operated during the ten year period of study (6 males and 3 females). The median age at onset of symptoms was 06 months (01 day-36 months) and the median age of reporting to the hospital was 07 months (01 day-44 months) with a mean delay of 5 months between onset of symptoms and reporting to hospital. Six patients (67%) had associated anomalies including one with posterior urethral valve which has been reported for the first time in literature. Four out of five (80%) late presenters underwent an upper gastrointestinal endoscopy for diagnostic confirmation. All patients were operated upon and Type 1 CPA was seen in five patients (56%), Type 2 in two patients (33%) and Type 3 in one patient (11%). The overall survival was 89% as one patient with associated Epidermolysis Bullosa expired after 4 months due to fulminant sepsis. Three patients were lost to follow up and amongst the remaining five; the median follow up period is 36 months.

CONCLUSION

CPA is a rare entity that may present late with subtle signs like failure to thrive and nonbilious vomit. A high index of suspicion is mandated in these cases and an Upper Gastrointestinal Endoscopy will help in early diagnosis and avoid further unnecessary investigations. A feeding jejunostomy may benefit malnourished sick children before definitive surgery.

LEVEL OF EVIDENCE

Level 3, Type of study: Retrospective study.

Failure to Thrive in the Context of Carney Complex

BACKGROUND/AIMS

Carney complex (CNC) is a rare syndrome associated with multiple tumors and several other unique manifestations. We describe the clinical, genetic, and laboratory findings in a cohort of patients with CNC and failure to thrive (FTT).

METHODS

A retrospective case series of pediatric patients with CNC presenting with FTT.

RESULTS

We describe a patient with infantile Cushing syndrome (CS) who presented with severe FTT and liver disease; the patient was subsequently diagnosed with CNC. This led to the realization that at least 10 other patients with CNC and FTT have been investigated in the last 22 years at the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Four of those had primary pigmented nodular adrenocortical disease (PPNAD), 2 had cardiac myxomas, and 3 had liver disease.

CONCLUSION

Pediatric patients with CNC may present with FTT whose primary cause is variable and includes CS due to PPNAD, hepatic involvement, and other manifestations of CNC. FTT due to liver disease and/or other causes is a unique new presentation of this rare syndrome with which clinicians need to be familiar.

Endoscopic Balloon Dilation for Treatment of Congenital Antral Web

Congenital antral webs are a rare but relevant cause of gastric outlet obstruction in infants and children. The condition may lead to feeding refusal, vomiting, and poor growth. Due to the relative rarity of the disease, cases of congenital antral web are frequently misdiagnosed or diagnosed with significant delay as physicians favorably pursue diagnoses of pyloric stenosis and gastric ulcer disease, which are more prevalent. We report a case of an eight-month-old female who presented with persistent non-bilious emesis, feeding difficulties, and failure to thrive and was discovered to have an antral web. The web was successfully treated with endoscopic balloon dilation, which resolved her symptoms. Two years later, the patient remains asymptomatic and is thriving with weight at the 75th percentile for her age.

Using donor human milk to feed vulnerable term infants: a case series in KwaZulu Natal, South Africa

BACKGROUND

Donor human milk is the World Health Organization's recommendation for infant feeding when the mother's own breast milk is unavailable. Breast milk has been shown to reduce morbidity and mortality and in low birthweight infants, donor milk reduces the incidence of necrotising enterocolitis, late onset sepsis and improves outcomes. There is a paucity of literature documenting outcomes of using donor human milk in older children who need additional support for a variety of health issues.

CASE PRESENTATION

A series of seven case studies is presented of orphaned and abandoned children, many of whom were either HIV exposed or positive. All children were fed with pasteurised donor human milk at a transition home and their progress reported.

CONCLUSIONS

Although detailed medical records were not always available, the case studies provide anecdotal evidence of the protective effects of donor human milk against failure to thrive, diarrhoea, atopic dermatitis, and opportunistic infections.

Heterozygous mutations in the cholesterol side-chain cleavage enzyme gene (CYP11A1) can cause transient adrenal insufficiency and life-threatening failure to thrive

The first and rate-limited step of steroidogenesis in all steroidogenic tissues is the conversion of cholesterol to pregnenolone, catalysed by P450scc side-chain cleavage enzyme (CYP11A1 gene-SCC). SCC deficiency has been characterised as an autosomal recessive disorder, although it may also be inherited as an autosomal dominant trait in humans. Here, we describe a family of three members carrying the same novel heterozygous CYP11A1 mutation, a c.235G > A missense variant in exon 1: pVal79Ile. A 46 XY boy (P1) was presented at the age of 3 months with early onset adrenal insufficiency and life-threatening failure to thrive, with low adrenal androgens but normal external genitalia. Five years later, the parents had twin girls, one of whom (P2) presented acute adrenal crisis a few hours after birth. The father (P3), born at term, was reported as having suffered from failure to thrive during the neonatal period, though not his only male sibling. This report of severe early adrenal insufficiency caused by a heterozygous mutation of the CYP11A1 gene clearly demonstrates that SCC deficiency may be inherited as an autosomal dominant trait in humans.

Achalasia Cardia in a Young Infant

Achalasia cardia is an esophageal motility disorder rarely reported in children and more so in young infants. Common clinical presentations include vomiting, dysphagia, regurgitation, recurrent pulmonary aspiration and failure to thrive. Diagnosis is made by barium swallow study and esophageal manometry, which is the gold standard test. Pharmocological management and endotherapy often fails and results in recurrence of symptoms. Laparoscopic Hellers myotomy, with or without anti-reflux procedure is the standard treatment of choice for children. Per-oral endoscopic myotomy is utilized for treatment of achalasia in adults, but its safety, efficacy, and feasibility is not studied in children.

"It's a Long-Term Process": Description of Daily Family Life When a Child Has a Feeding Disorder

Pediatric feeding problems occur in 25% of the general pediatric population and up to 80% of those who have developmental delays. When feeding problems place the child at nutritional risk, families are typically encouraged to increase their child's intake. Family mealtime can become a battle, which further reinforces problematic feeding behaviors from the child and intensifies well-intentioned but unguided parental mealtime efforts. Family has an essential influence on feeding; however, studies to date neglect to address the family context of feeding difficulty. In this study we describe, in the context of everyday life, family management of feeding when a child had a significant feeding problem. Parents of children with feeding problems were interviewed with the Family Management Style Framework components as a guide. Twelve parents participated, representing nine families of children with feeding disorder. Description of family management of feeding provides a foundation for development of family feeding interventions.

Acute kidney injury in necrotizing enterocolitis predicts mortality

BACKGROUND

Morbidity and mortality with necrotizing enterocolitis (NEC) remains a significant challenge. Acute kidney injury (AKI) has been shown to worsen survival in critically ill neonates. To our knowledge, this study is the first to evaluate the prevalence of AKI and its impact on outcomes in neonatal NEC.

METHODS

We carried out a single-center retrospective chart review of all neonates treated for NEC between 2003 and 2015 (N = 181). AKI is defined as a rise in serum creatinine (SCr) from a previous trough according to neonatal modified KDIGO criteria (stage 1 = SCr rise 0.3 mg/dL or SCr 150 < 200%, stage 2 = SCr rise 200 < 300%, stage 3 = SCr rise ≥300%, SCr 2.5 mg/dL or dialysis). Primary outcome was in-hospital mortality and secondary outcomes were hospital length of stay (LOS) and need for and type of surgery.

RESULTS

Acute kidney injury occurred in 98 neonates (54%), with 39 stage 1 (22%), 31 stage 2 (18%), and 28 stage 3 (16%), including 5 requiring dialysis. Non-AKI and AKI groups were not statistically different in age, weight, Bell's NEC criteria, and medication exposure (vasopressors, vancomycin, gentamicin, or diuretic). Neonates with AKI had higher mortality (44% vs 25.6%, p = 0.008) and a higher chance of death (HR 2.4, CI 1.2-4.8, p = 0.009), but the effect on LOS on survivors did not reach statistical significance (79 days, interquartile range [IQR] 30-104 vs 54 days, IQR 30-92, p = 0.09). Overall, 48 (27.9%) patients required surgical intervention.

CONCLUSIONS

This study shows that AKI not only occurs in over half of patients with NEC, but that it is also associated with more than a two-fold higher mortality, highlighting the importance of early recognition and potentially early intervention for AKI.

The Association between Failure to Thrive or Anemia and Febrile Seizures in Children between 6 Months to 6 Years Old Age

OBJECTIVES

Febrile seizure is the most common seizure disorder in childhood. Anemia or failure to thrive can predispose children to febrile seizure by affecting the nervous system function. The current study investigated the association between febrile seizures and anemia or failure to thrive.

MATERIALS AND METHODS

This case-control study was performed on 307 children 6 months to 6 yr old age hospitalized at the Ali Asghar Children`s Hospital, Tehran, Iran from 2011 to 2014 divided into two groups as follows: A case group including 158 children with febrile seizures and a control group including 149 febrile children without seizure. The amount of Hgb, Hct, RBC count, MCV, MCH, and MCHC was recorded and weight-for-age and weight-for-height was calculated based on the WHO Z-Score charts. The data were compared between two groups.

RESULTS

There were no differences regarding age and sex between the groups. Statistically significant differences were found regarding the mean RBC count between the case group (4.38×10⁶ ± 0.72×10⁶) and the control group (4.24×10⁶ ± 0.84×10⁶) (P=0.013), as well as about the mean MCV that was 78.73 ± 0.97 and 76.78 ± 1.00 in the case and control groups, respectively (P=0.005). Anemia was seen in 28.5% of the cases and 42.3% of control group which was statistically significant (P=0.012). There was not statistically significant difference regarding failure to thrive between two groups.

CONCLUSION

In children with febrile seizures, anemia was lower comparing with febrile children without seizure. Moreover, there was not any association between failure to thrive and febrile seizures.

Effects of zinc supplementation on catch-up growth in children with failure to thrive

BACKGROUND/OBJECTIVES

Although globally the numbers of children diagnosed with failure to thrive (FTT) have decreased, FTT is still a serious pediatric problem. We aimed to investigate the effects of zinc supplementation for 6 months on growth parameters of infants and children with FTT.

SUBJECTS/METHODS

In this retrospective study, of the 114 participants aged between 4 months and 6 years, 89 were included in the zinc supplementation group and were provided with nutrition counseling plus an oral zinc supplement for 6 months. The caregivers of the 25 participants in the control group received nutrition counseling alone. Medical data of these children, including sex, age, height, weight, serum zinc level, and serum insulin-like growth factor 1 (IGF1) level were analyzed.

RESULTS

Zinc supplementation for 6 months increased weight-for-age Z-score and serum zinc levels (5.5%) in the zinc supplementation group of underweight category children. As for stunting category, height-for-age Z-score of the participants in the zinc supplementation group increased when compared with the baseline, and serum zinc levels increased in the normal or mild stunting group. Serum IGF1 levels did not change significantly in any group. Thus, zinc supplementation was more effective in children in the underweight category than those in the stunted category; this effect differed according to the degree of the FTT.

CONCLUSION

These findings suggest that zinc supplementation may have beneficial effects for growth of infants and children with FTT, and zinc supplementation would be required according to degree of FTT.

Vomiting in an infant with congenital nephrotic syndrome: Questions

BACKGROUND

Most patients with congenital nephrotic syndrome (CNS) exhibit a failure to thrive. A previous study reported that five of 41 (12 %) infants with CNS had hypertrophic pyloric stenosis (HPS) requiring surgery. The reason for this is undetermined, and there are few reports regarding the relationship between these conditions or their clinical course.

CASE DIAGNOSIS/TREATMENT

We present the case of a 4-month-old girl with CNS. She did not show typical manifestations of HPS, but thickened mucosal and submucosal layers and hypertrophy of the pyloric muscle were detected by repeated ultrasound examinations prior to the diagnosis of HPS. Pyloroplasty was performed to improve her poor weight gain and led to ideal growth.

CONCLUSIONS

Our case indicates that obstruction of the gastric outlet may be strongly associated with poor weight gain in patients with CNS. We should suspect involvement with HPS even if typical symptoms are lacking, and an aggressive intervention may improve poor growth. Thickened edematous mucosal and submucosal layers at the pyloric antrum have the potential to cause the high frequency of HPS in CNS.

Zoledronic acid for neonatal subcutaneous fat necrosis

Subcutaneous fat necrosis (SFN) in infants producing severe hypercalcemia is a life-threatening emergency. Pathophysiology may include enhanced gastrointestinal calcium absorption and bone resorption. We treated an infant with SFN and serum calcium of 15 mg/dL with prednisolone and low-dose zoledronic acid. Serum calcium promptly normalized without rebound hypocalcemia, and redosing of zoledronic acid was not necessary.

Multicenter study on the effectiveness of the pre-epiglottic baton plate for airway obstruction and feeding problems in Robin sequence

Background

Treatment of Robin sequence is often either invasive or of unproven effectiveness. The pre-epiglottic baton plate (PEBP) is a well-studied alternative, yet is not widely applied internationally. We report on a prospective 3-center cohort study investigating this treatment. Based on an agreed protocol, parents of infants with Robin sequence referred to participating centers were offered enrollment, which involved taking a maxillary cast followed by endoscopy to fit the plate and sleep studies to monitor its effectiveness. Recordings were centrally analyzed by sleep specialists blinded to timing and center. Primary outcome was the mixed-obstructive apnea index, defined as the number of such apneas/h of sleep; secondary outcomes included the desaturation index to <80% pulse oximeter saturation and weight gain.

Results

Of 75 infants referred, 49 could be included; 1 center failed to perform appropriate sleep studies. Within a mean hospitalization of 3 weeks, the mixed-obstructive apnea index decreased (median; interquartile range) from 15.9 (6.3–31.5) to 2.3 (1.2–5.4); it decreased further to 0.7 (0.1–2.4) in the 32 infants who had a successful 3-month follow-up sleep study performed. The desaturation index normalized (from 0.38 (0–2.7) to 0.0 (0–0.1)). Mean standard deviation score for weight remained unchanged between admission and follow-up, while the proportion of tube-fed infants decreased from 74 to 14%.

Conclusions

This prospective multi-center cohort study confirms retrospective audits on the effectiveness of PEBP treatment in improving upper airway obstruction and feeding problems, the main clinical problems of infants with Robin sequence. International collaboration is required to compare this with other treatment approaches.

Trial registration

Number NCT02266043, Registered 30/09/2014; registered partially retrospectively.

Serum and Hair Mineral Levels in Children with Failure to Thrive According to the Type of Feeding Difficulties

This study evaluated serum and hair mineral and trace element levels as well as levels of other nutritional factors affecting growth and appetite in young children with non-organic failure to thrive (NOFTT) based on the presence or types of feeding difficulty (FD). Between August 2012 and July 2015, 136 children less than 6 years of age with NOFTT were included. FD was diagnosed based on Wolfson criteria and divided into subtypes according to Chatoor's classification. Clinical data were reviewed, and serum and hair mineral levels were measured. Of all assessed serum and hair minerals, only hair sulfur contents differed significantly between subjects with and without infantile anorexia (39,392 ± 2211 vs. 40,332 ± 2551 μg/g, P = 0.034). There were no differences in serum and hair mineral levels between children with and without sensory food aversion. Hair copper contents were significantly lower in children with FD of reciprocity (12.3 ± 6.0 vs. 22.4 ± 25.1 μg/g, P = 0.049). While hair zinc contents were also lower, the difference was not statistically significant (49.2 ± 26.8 vs. 70.6 ± 41.0 μg/g, P = 0.055). Only hair manganese contents were significantly lower in children with posttraumatic FD (0.12 ± 0.04 vs. 0.26 ± 0.73 μg/g, P = 0.037). In conclusion, there were no differences in most serum and hair mineral levels in children with NOFTT, except for relatively lower hair levels of sulfur, copper and possibly zinc, and manganese in infantile anorexia, reciprocity, and posttraumatic types of FD, respectively.

Clinical Outcome for Congenital Diaphragmatic Hernia at the Age of 1 Year in the Era of Fetal Intervention

BACKGROUND

Congenital diaphragmatic hernia (CDH) is an abnormal development of the diaphragm leading to high neonatal mortality and morbidity. Beyond the neonatal period, prospective data on overall long-term outcome in CDH survivors is scarce. In particular, for those treated with fetoscopic endoluminal tracheal occlusion (FETO), a promising new technique to increase survival chances for severe cases, the outcomes are even less documented.

AIM

To prospectively document the clinical outcome of CDH at 1 year including FETO-treated infants in relation to ante- and postnatal variables.

METHODS

A single-centre prospective clinical follow-up at 1 year of age included a standardised respiratory questionnaire.

RESULTS

Thirty-four CDH survivors were included, 10 of which were FETO-treated infants. At 1 year, the median weight z score was -1.50 (interquartile range [IQR]: -2.45 to -0.88) and 10/34 were "failure to thrive" (FTT) cases. Gastro-intestinal (GI) problems at 1 year were mainly related to gastro-oesophageal reflux (16/34) with a high need for tube feeding in the first year (9/34). Tachypnoea was present in 10/29 (34%) and 8/34 (24%) were on chronic inhaled medication. The median total respiratory symptom score was 20 (IQR: 13-32) and correlated with the number of neonatal ventilation days (p = 0.048). Hospital re-admission occurred in 19/34 infants (56%), and was for respiratory problems in almost half of them (8/19).

CONCLUSION

In this CDH cohort, morbidity at 1 year was determined more by GI problems and FTT than respiratory morbidity. The respiratory questionnaire may, however, have underestimated the respiratory morbidity since respondents had a 1-in-4 chance to have persistent tachypnoea and be on chronic inhalation therapy.

Microvillus inclusion disease: a subtotal enterectomy as a bridge to transplantation

BACKGROUND

Microvillus inclusion disease (MVID) is a known congenital cause of intractable diarrhea resulting in permanent intestinal failure. There is need for a lifelong total parenteral nutrition (TPN) from diagnosis and the prognosis is poor. Most patients die by the second decade of life as a result of complications of parenteral alimentation including liver failure or sepsis. The only available treatment at this moment is a small bowel transplantation. But before that moment, the patients often suffer from a persistent failure to thrive and electrolyte disturbances despite continuous TPN.

METHODS AND RESULTS

We report what we believe is a first case of an extensive small bowel resection in a 5-month-old boy with proven MVID to act as a bridge to (liver-) intestinal transplantation to treat failure to thrive and intractable diarrhea.

CONCLUSIONS

An extensive small bowel resection can be done to enhance the chance of survival leading up to the transplantation by managing fluid and electrolyte imbalance. It facilitates medical management of these patients and makes a bowel transplantation possible at a later stage.

[Supraglottoplasty for pediatric laryngomalacia : Results from 71 cases]

Laryngomalacia is the most common cause of stridor in infants. The stridor is caused by an inward collapse of supraglottic structures during inspiration resulting in an inspiratory stridor. The exact etiology still remains unclear. The surgical procedure of choice for laryngomalacia is supraglottoplasty. From 2009 to 2016 a total of 71 children were treated by supraglottoplasty in the department for pediatric otorhinolaryngology of the Stuttgart Hospital. The indications for supraglottoplasty were laryngomalacia with severe inspiratory stridor, oxygen desaturation, suprasternal or chest retraction, feeding difficulties and/or failure to thrive. The overall success rate was 86 % but there was a clear difference between children with isolated laryngomalacia and the group with associated comorbidities. The success rate for patients with isolated laryngomalacia was 98 % and for patients with associated comorbidities 57 %. Supraglottoplasty is therefore an effective and safe treatment for symptomatic laryngomalacia and a reduction in the success rate showed a clear correlation with the presence of congenital comorbidities.

Overall Profile of a Pediatric Multidisciplinary Feeding Clinic

Objective

To evaluate the overall profile of children with feeding disorders and their relationships to medical conditions in an outpatient feeding clinic of a tertiary hospital.

Methods

The medical records of 143 children who had visited the feeding clinic between January 2010 and June 2014 were reviewed retrospectively. The presence of a feeding disorder (feeding behavior disorder, dysphagia, and/or failure to thrive [FTT]) and the children's medical conditions were examined by a physiatrist.

Results

Half of the patients (n=74, 51.7%) were under 15 months of age, and 68 (47.6%) were born preterm. Ninety-three patients (65.0%) met the criteria for any combination of feeding behavior disorder, dysphagia, or FTT. Cardiorespiratory disease was the most common medical condition; children with this condition were more likely to show sensory food aversion and FTT. Feeding behavior disorders were significantly associated with gastrointestinal problems, and dysphagia was significantly related to almost all medical conditions.

Conclusion

A multidisciplinary approach to children with feeding difficulties is proposed for comprehensive evaluation and treatment because combinations of feeding problems are very common among children. This overall profile could provide clinicians with a clear understanding of the complexity of feeding disorders and their relationships with various medical conditions in children.

Developmental delay and failure to thrive in a 7-month-old baby boy with spontaneous transient Graves' thyrotoxicosis: a case report

BACKGROUND

Thyroid dysfunction can induce developmental delay and failure to thrive in infancy. Congenital hypothyroidism is one of the common causes of these symptoms in infancy. By contrast, hyperthyroidism is a rare cause of these symptoms in infancy.

CASE PRESENTATION

A 7-month-old Japanese baby boy was examined for developmental delay and failure to thrive. Blood tests were performed, which showed low levels of thyroid-stimulating hormone (<0.01 μU/mL) and high levels of free thyroxine (2.14 pg/mL). He was referred to our hospital at 8 months of age. His height was 64 cm (-2.7 standard deviation) and his weight was 6085 g (-2.5 standard deviation). No goiter was detected on examination. His thyrotropin receptor antibody was slightly high (3.9 IU/L), whereas thyroid stimulating antibody, anti-thyroglobulin antibody, and thyroid peroxidase antibody were within normal range. These blood findings indicated hyperthyroidism, most likely Graves' disease. His free thyroxine level decreased in the first month after our examination. No increased vascularity of his thyroid gland was noted. The technetium uptake of his thyroid gland in scintigraphy was relatively increased compared to the intake of his salivary gland. We elected to observe rather than treat with anti-thyroid medications.

CONCLUSION

We have to rule out spontaneous transient Graves' thyrotoxicosis when babies have symptoms of developmental delay and fail to thrive.

A rare type of congenital Sturge-Weber Syndrome: presenting with history of perinatal asphyxia

The presentation of a newborn with perinatal asphyxia and poor developmental milestones in a resource-poor setting. Many a times, obscured, unsuspected, and uncommon etiologies compound well-known causes of failure to thrive; in this case a rare finding of Type III Sturge-Weber Syndrome was revealed by Brain CT scanning.

Presentation and management of pulmonary sequestration with total visceral inflow and outflow

Two of the most common types of congenital thoracic malformations are congenital pulmonary airway malformations (CPAMs) and bronchopulmonary sequestrations (BPS). Here we present the first known case of a hybrid lesion, with coexisting features of an extralobar sequestration (ELS) and CPAM type 2, with arterial inflow from the celiac trunk and venous outflow to the portal vein. The clinical presentation, investigative imaging and timing of surgery are discussed.

Investigating Transitional Care to Decrease Post-pancreatectomy 30-Day Hospital Readmissions for Dehydration or Failure to Thrive

BACKGROUND

Current literature emphasizes post-operative complications as a leading cause of post-pancreatectomy readmissions. Transitional care factors associated with potentially preventable conditions such as dehydration and failure to thrive (FTT) may play a significant role in readmission after pancreatectomy and have not been studied.

METHODS

Thirty-one post-pancreatectomy patients, who were readmitted for dehydration or FTT between 2009 and 2014, were compared to 141 nonreadmitted patients. Medical record review and a questionnaire-based survey, specifically designed to assess transitional care, were used to identify predictors of readmissions for dehydration or FTT. Logistic regression models were used to evaluate outcomes.

RESULTS

On multivariable analysis, the strongest predictors of readmission for dehydration and FTT were the patient's lower educational level (P = 0.0233), the absence of family during the delivery of discharge instructions (P = 0.0098), episodic intermittent nausea at discharge (P = 0.0019), uncertainty about quantity, quality, or frequency of fluid intake (P = 0.0137), and the inability or failure to adhere to the clinician's instructions in the outpatient setting (P = 0.0048).

CONCLUSION

Transitional-care-related factors are found to be associated with post-pancreatectomy readmission for dehydration and FTT. Using these results to identify high-risk patients and implement focused preventive measures combining efficient communication and optimal inpatient and outpatient management could potentially decrease readmission rates.