An unusual cause of failure to thrive in a child

Classic Bartter syndrome, depending on the severity, presents during childhood or adolescence as failure to thrive and may be incorrectly labelled as protein-energy malnutrition, particularly in children from a low socioeconomic stratum. We encountered a 5-year-old boy who was asymptomatic till the age of 3 years. Despite adequate dietary intake, he was admitted and managed in various hospitals as a case of protein-energy malnutrition. On evaluation, he had unusual features in the form of persistent hypokalaemia and polyuria leading us to suspect a renal tubular disorder. Treatment of the condition resulted in good weight gain and normalization of serum electrolytes.

Noonan syndrome and clinically related disorders

Noonan syndrome is a relatively common, clinically variable developmental disorder. Cardinal features include postnatally reduced growth, distinctive facial dysmorphism, congenital heart defects and hypertrophic cardiomyopathy, variable cognitive deficit and skeletal, ectodermal and hematologic anomalies. Noonan syndrome is transmitted as an autosomal dominant trait, and is genetically heterogeneous. So far, heterozygous mutations in nine genes (PTPN11, SOS1, KRAS, NRAS, RAF1, BRAF, SHOC2, MEK1 and CBL) have been documented to underlie this disorder or clinically related phenotypes. Based on these recent discoveries, the diagnosis can now be confirmed molecularly in approximately 75% of affected individuals. Affected genes encode for proteins participating in the RAS-mitogen-activated protein kinases (MAPK) signal transduction pathway, which is implicated in several developmental processes controlling morphology determination, organogenesis, synaptic plasticity and growth. Here, we provide an overview of clinical aspects of this disorder and closely related conditions, the molecular mechanisms underlying pathogenesis, and major genotype-phenotype correlations.

A Turkish case of congenital chloride diarrhea with SLC26A3 gene (c.2025_2026insATC) mutation: diagnostic pitfalls

Congenital chloride diarrhea is a rare autosomal recessively inherited disorder characterized by impairment of Cl-/HCO3- exchange in an otherwise normal distal ileum and colon. Infrequency of congenital chloride diarrhea makes diagnostics difficult. The typical presentation is watery Cl- rich diarrhea, hypochloremia, hypokalemia, metabolic alkalosis and failure to thrive. This is a report of a Turkish female infant who was falsely diagnosed with Bartter syndrome when she was two months old. Ibuprofen was commenced at that time. However, severe watery diarrhea, dehydration, failure to thrive, abdominal distention, and electrolyte abnormalities persisted. She was diagnosed with congenital chloride diarrhea based on high fecal Cl- level and SLC26A3 gene c.2025_2026insATC mutation at the age of eight months. Oral NaCl and KCl supplementation was started. Our patient is now 26 months old. Her growth and development are normal. Early diagnosis and treatment are essential for normal growth and development and prevention of other severe complications of congenital chloride diarrhea.

Diagnosis on a positive fashion of nonorganic failure to thrive

AIMS

To study the predictive value of predefined symptoms and signs for allocating children into one of two groups: nonorganic and organic failure to thrive.

PATIENTS AND METHODS

Two hundred eight outpatients (6 months-14 years old) suffering from failure to thrive (FTT) were included in the study. Predefined symptoms and signs were considered as potential predictors of organic/nonorganic failure to thrive. All patients underwent an established diagnostic work up in order to exclude organic causes of FTT.

RESULTS

The percentage of patients without any organic symptom (negative predictive value), who were diagnosed as NOFTT was 92%; the percentage of patients having nonorganic symptoms only (positive predictive value), who were diagnosed as NOFTT was 96%, while their absence does not exclude a NOFTT diagnosis as well (negative predictive value = 41%).

CONCLUSION

The detection of at least one nonorganic symptom or sign, with the exclusion of any organic symptom, can support a diagnosis of nonorganic FTT and therefore only few laboratory investigations seem to be warranted.

Acrodermatitis enteropathica–like eruption and failure to thrive as presenting signs of cystic fibrosis

We describe a female infant with an acrodermatitis enteropathica-like eruption as the presenting sign of rapidly fatal cystic fibrosis. The patient had growth retardation, developed an erythematous eruption unresponsive to oral zinc, and finally a generalized erosive dermatitis with associated edema, anemia and hypoproteinemia.

Hospital admissions for respiratory symptoms and failure to thrive before and after Nissen fundoplication

PURPOSE

The purpose of this study is to determine whether Nissen fundoplication decreases hospital admissions for respiratory symptoms and failure to thrive (FTT).

METHODS

A retrospective study using discharge abstract data from Southern California Kaiser Permanente hospitals during the last decade was done. Three hundred forty-two pediatric patients had at least one Nissen fundoplication. Hospital admissions for aspiration and other pneumonia, respiratory distress/apnea, and FTT were determined before and after Nissen fundoplication. Age and associated neurologic disorders were also studied. Statistical analysis was determined by chi(2) analysis, Poisson regression analysis, and relative risk.

RESULTS

The number of patients requiring hospital admission for aspiration and other pneumonia, respiratory distress/apnea, and FTT was similar before and after Nissen fundoplication. The proportion of readmission within 1 year after Nissen fundoplication for aspiration pneumonia was 0.1250 (95% confidence interval [CI], 0.0266-0.3236); other pneumonia, 0.5465 (95% CI, 0.4355-0.6542); respiratory distress/apnea, 0.5039 (95% CI, 0.4145-0.5931); and FTT, 0.5669 (95% CI, 0.4761-0.6545). Associated neurologic disorders independently increased hospital admissions for aspiration and other pneumonia, respiratory distress/apnea, and FTT. Age was inversely related to hospital admissions for respiratory distress and FTT.

CONCLUSION

Nissen fundoplication did not improve hospital admissions for pneumonia, respiratory distress/apnea, and FTT. Associated neurologic disorders increased readmissions for pneumonia, respiratory distress/apnea, and FTT, whereas increasing age decreased readmission for respiratory distress and FTT.

A neglected case of renal tubular acidosis

In this report, we present a case of a child with distal renal tubular acidosis, severe failure to thrive and profound rickets, who was only 7.8 Kg when presented at 6 years of age. His response to treatment and his follow-up for four years is discussed. Although failure to thrive is a common finding in renal tubular acidosis but the physical and x-ray findings in our case were unique.

Diagnostic challenges in a severely delayed infant with hypersomnolence, failure to thrive and arteriopathy: a unique case of gamma-hydroxybutyric aciduria and Williams syndrome

Metabolic work-up, pursued in a 5-month-old female infant with hypersomnolence, failure to thrive, and global developmental delay, led to the identification of gamma-hydroxybutyric aciduria (GHB). Succinic semialdehyde dehydrogenase deficiency (SSADH deficiency) was confirmed enzymatically and molecularly. Characteristic dysmorphic facies, cardiovascular anomalies, and hypercalcemia led to clinical suspicion of Williams-Beuren syndrome (WS), confirmed by cytogenetic studies. This rare occurrence of two unrelated genetic conditions highlights the importance of instituting comprehensive metabolic studies despite the presence of syndromic findings, even in the absence of other metabolic abnormalities that may be indicative of metabolic disease such as hyperammonemia, hypoglycemia, ketonuria, and metabolic acidosis.

[Eating disorders in children and adolescents]

Eating disorders in infants,young children and adolescents differ in theirfrequency, accompanying symptoms and the investigative steps required. Within the framework of a guideline-oriented, multimodal therapeutic approach, disorder-specific and evaluated treatment concepts have proved successful. Before initiating treatment, however, the question as to whether it should be done on an ambulatory or an inpatient basis must be decided.

[Severe hypernatraemic dehydration in collodion baby]

Case report on severe hypernatraemic dehydration in a non-recognised collodion baby who also suffered from hydrops fetalis caused by supraventricular tachycardia. Excessive transcutaneous fluid loss caused s-Na+ reaching 182 mmol/l within 36 hours of birth. The infant was cautiously rehydrated during the following three days. No sign of neurologic impairment was observed. It is emphasized that early observation of the collodion baby must take place in a humidified incubator. Major weight changes in the newborn should always result in analysis of serum sodium.

Citrin deficiency: a novel cause of failure to thrive that responds to a high-protein, low-carbohydrate diet

The proband was born at 36 weeks, appropriate for gestational age, to nonconsanguineous white parents. There was no evidence of hyperbilirubinemia or intrahepatic cholestasis in the neonatal period, and she had normal newborn screen results. She presented with 3 episodes of life-threatening bleeding and anemia. The diagnostic evaluation for her bleeding diathesis revealed an abnormal clotting profile with no biochemical evidence for hepatocellular damage. She was incidentally noted to have severe growth deceleration that failed to respond to 502 kJ/kg (120 kcal/kg) per day of protein-hydrolyzed formula. An extensive diagnostic workup for failure to thrive, which was otherwise normal, included plasma amino acid analysis that revealed hyperglutaminemia and citrulline levels within the reference range. Testing of a repeat sample revealed isolated hypercitrullinemia. No argininosuccinic acid was detected. Her ammonia level and urine orotic acid were within the reference ranges. Subsequent plasma amino acid analysis exhibited a profile suggestive of neonatal intrahepatic cholestasis caused by citrin deficiency with elevations in citrulline, methionine, and threonine. Western blotting of fibroblasts demonstrated citrin deficiency, and a deletion for exon 3 was found in the patient's coding DNA of the SLC25A13 gene. On the basis of the experience with adults carrying this condition, the patient was given a high-protein, low-carbohydrate diet. The failure to thrive and bleeding diathesis resolved. When compliance with the dietary prescription was relaxed, growth deceleration was again noted, although significant bleeding did not recur. This is the first report of an infant of Northern European descent with citrin deficiency. The later age at presentation with failure to thrive and bleeding diathesis and without obvious evidence of neonatal intrahepatic cholestasis expands the clinical spectrum of citrin deficiency. This case emphasizes the importance of continued dietary control and growth monitoring in children with neonatal intrahepatic cholestasis caused by citrin deficiency and identifies a new metabolic entity responsible for failure to thrive.

Confusing terminology attempts to define the undefinable

Perspective on the papers by Olsen et al(see page 109) and Lucas et al(see page 120)

Failure to think about failure to thrive

Perspective on the paper by Olsen et al (see page 109)

Image or reality: why do infant size and growth matter to parents?

Perspective on the paper by Lucas et al(see page 120)

A systematic review of lay views about infant size and growth

OBJECTIVES

To understand lay views on infant size and growth and their implications for a British population.

METHODS

A systematic review of parental and other lay views about the meanings and importance of infant size and growth using Medline, PsycInfo, CINAHL, Sociological Abstracts, IBSS, ASSIA, British Nursing Index ChildData, Caredata, SIGLE, Dissertation Abstracts (US), Index to Theses. 19 studies, most of which reported the views of mothers, from the US, Canada, the UK and Finland were reviewed.

RESULTS

Notions of healthy size and growth were dominated by the concept of normality. Participants created norms by assessing and comparing size and growth against several reference points. When size or growth differed from these norms, explanations were sought for factors that would account for this difference. When no plausible explanation could be found, growth or size became a worry for parents.

CONCLUSIONS

Parents consider the importance of contextual factors when judging what is appropriate or healthy growth. For public health advice to be effective, lay, as well as scientific, findings and values need to be considered.

Failure to thrive: the prevalence and concurrence of anthropometric criteria in a general infant population

BACKGROUND

Failure to thrive (FTT) in early childhood is associated with subsequent developmental delay and is recognised to reflect relative undernutrition. Although the concept of FTT is widely used, no consensus exists regarding a specific definition, and it is unclear to what extent different anthropometric definitions concur.

OBJECTIVE

To compare the prevalence and concurrence of different anthropometric criteria for FTT and test the sensitivity and positive predictive values of these in detecting children with "significant undernutrition", defined as the combination of slow conditional weight gain and low body mass index (BMI).

METHODS

Seven criteria of FTT, including low weight for age, low BMI, low conditional weight gain and Waterlow's criterion for wasting, were applied to a birth cohort of 6090 Danish infants. The criteria were compared in two age groups: 2-6 and 6-11 months of life.

RESULTS

27% of infants met one or more criteria in at least one of the two age groups. The concurrence among the criteria was generally poor, with most children identified by only one criterion. Positive predictive values of different criteria ranged from 1% to 58%. Most single criteria identified either less than half the cases of significant undernutrition (found in 3%) or included far too many, thus having a low positive predictive value. Children with low weight for height tended to be relatively tall.

CONCLUSIONS

No single measurement on its own seems to be adequate for identifying nutritional growth delay. Further longitudinal population studies are needed to investigate the discriminating power of different criteria in detecting significant undernutrition and subsequent outcomes.

[Ventricular septal defects: anatomic, clinical, therapeutic and prognostic aspects. 44 cases]

OBJECTIVES

The aim of this study is to analyze epidemiologic, anatomic, clinical and prognostic aspects of ventricular septal defect (VSD) in the pediatric population in Morocco.

METHODS

This retrospective descriptive study included 44 consecutive patients admitted to the cardiology B department of Rabat University Hospital Center from January 2000 through March 2003. The inclusion criteria were: VSD, isolated or associated with other left-right shunt defects, diagnosed by transthoracic echocardiography, and hospitalized in the service.

RESULTS

VSD accounted for 10.6% of the congenital cardiac diseases hospitalized in our department. Patients' mean age was 2.25 +/- 2.6 years; the consanguinity rate was 29%. The primary clinical symptoms were dominated by failure to gain weight (84%), exertional dyspnea (82%), and repeated bronchitis (72%). Early complications were infundibular stenosis (4 cases), aortic regurgitation (3 cases), and infectious endocarditis (1 case). Nine children had other abnormalities, including 6 with trisomy 21. Echocardiography showed that membranous defects were by far the most common type (88%). All patients received symptomatic medical treatment. Only 31.7% (n=14) had surgery: 11.3% (n=5) to close the hole (corrective) and 20.4% (n=9) for pulmonary artery (palliative) banding. After two years of follow-up, those with surgical correction were all doing well.

CONCLUSION

Surgically closing the VSD is the best way to avoid irreversible pulmonary arterial hypertension; banding should be only a temporary measure while awaiting corrective surgery.

[Transient pseudohypoaldosteronism in infants with vesicoureteral reflux]

BACKGROUND

Congenital urologic malformations occur with an incidence of 1:100 to 1: 200, leading to an increased risk of urinary tract infections. However, most patients remain without symptoms; serious electrolyte imbalance is rare.

MATERIAL AND METHODS

We report two infants who were admitted to hospital because of failure to thrive and poor weight gain. Both children had severe hyponatraemia and hyperkalaemia. Further work-up established pseudohypoaldosteronism secondary to dilated vesicoureteral reflux and urinary tract infection. Based on a literature search in PubMed, a short overview of this rare condition is presented.

RESULTS AND INTERPRETATION

Infants younger than 6 months of age with urologic malformations, and in most cases concomitant urinary tract infections, may develop secondary pseudohypoaldosteronism. The pathogenesis of this condition is probably a result of high intrarenal pressure, inflammation and immaturity of the tubular function leading to tubular resistance to aldosterone. The major symptoms are failure to thrive, poor weight gain, and signs of dehydration. Laboratory studies show hyponatraemia, hyperkalaemia and high levels of plasma renin activity and aldosterone. Treatment involves fluid resuscitation, sodium supplementation and antibiotic treatment of concomitant urinary tract infection. The most important differential diagnosis is the salt-losing form of congenital adrenal hyperplasia. A thorough endocrinologic and urological work-up, including abdominal ultrasound examination and urine analysis, may lead to correct diagnosis and treatment.

The redefinition of failure to thrive from a case study perspective

Explaining failure to thrive (FTT) in dichotomous terms--organic versus non-organic --no longer applies in the context of modern pediatric nursing. FTT has turned out to be much more multifaceted. One infant's story illustrates the complexities and long-term ramifications of a pediatric feeding disorder and the challenges faced by health care professionals and families in their care. The story illustrates how physiologic, sensorimotor, and behavioral issues can all impact a child's inability to gain weight as expected. With greater understanding, pediatric nurses can appreciate their role as members of a multidisciplinary pediatric feeding disorder team.

An approach to "failure to thrive"

BACKGROUND

Infants commonly present with failure to thrive. Psychosocial and nutritional causes are commonly responsible, but significant organic pathology requires exclusion in all children with failure to thrive.

OBJECTIVE

This article discusses an approach to the assessment of infants presenting with failure to thrive, together with information on management and available resources.

DISCUSSION

Close liaison between those involved in the management of infants presenting with failure to thrive--including family, maternal child health nurse, family doctor and paediatrician--should usually allow for appropriate intervention to correct the failure to thrive.

Adult failure to thrive in the older rehabilitation patient

Increasing numbers of older adults require rehabilitation therapy upon discharge from a hospital. This pilot study tested a tool developed to assess failure to thrive syndrome (FTT) in patients admitted to a long-term rehabilitation unit (N = 34), examined the association among commonly recognized FTT factors (persistent, unexpected impairment in physical function, cognitive impairment, and poor nutrition and mood state), and investigated relationships between FTT factors and discharge disposition. Patients with a high level of physical function differed from those with a low level of function in terms of age, mood state, and discharge disposition. Patients discharged home differed from patients who were unable to return home in mood state, physical function score, and admission serum albumin. Suggestions for practice and further research are offered.

The Copenhagen County child cohort: design of a longitudinal study of child mental health

BACKGROUND

Epidemiological studies of psychopathology in the first years of life are few, and the association between mental health problems in infancy and psychiatric disturbances later in life has not been systematically investigated. The aim of the present project was to study mental health problems and possibilities of intervention from infancy and onward.

METHODS

The basic study population consists of a birth cohort of 6,090 children born in the year 2000 in the County of Copenhagen, the Copenhagen County Child Cohort, CCCC 2000. At stage one CCCC 2000 was established on data from the Civil Registration System, Danish national registers, and standardized, longitudinal data from the first year of living obtained by public health nurses. At stage two a subsample was assessed at 1(1/2) years of age concerning child psychiatric illness and associated factors in a case-control study nested in the cohort, including a random sample. Participation rate at stage one was 92%.

PERSPECTIVES

Ongoing studies of CCCC 2000 include studies of failure to thrive, register studies, and studies of the predictive validity of public health screening. A follow-up study concerning the prevalence of psychopathology at age 5 is planned.

SUMMARY

The Copenhagen County Child Cohort CCCC 2000 is a longitudinal study of mental health from infancy investigating psychopathology in early childhood. Results from this study will add to the knowledge of risk factors and course of mental health problems in childhood and contribute to the validation of the mental health screening made by public health nurses.

Netherton Syndrome with Extensive Skin Peeling and Failure to Thrive due to a Homozygous Frameshift Mutation in SPINK5

BACKGROUND

Netherton syndrome (NTS) is a rare autosomal recessive multisystem disorder characterized by congenital erythroderma and ichthyosis, hair shaft abnormalities and immune dysregulation. The disorder is caused by deleterious mutations in the SPINK5 gene, encoding the serine protease inhibitor LEKTI.

OBJECTIVE

Our objective was to investigate if the erythrodermic variant of peeling skin syndrome is also caused by SPINK5 mutations and to study the consequences of the disease on infantile brain development.

METHODS

In an infant with extensive erythroderma, peeling skin and failure to thrive, we analyzed the SPINK5 gene for pathogenic mutations by direct DNA sequencing and performed repeated brain MRI studies with diffusion-weighted imaging.

RESULTS

We identified a homozygous 4-base-pair insertion in exon 5 of SPINK5, which introduces a premature termination codon and appears to be a common mutation among West Indies islanders. MRI analyses revealed a persistent diffuse volume loss.

CONCLUSION

Our results confirm that early truncation mutations of the coding sequence of SPINK5 produce a severe phenotype and that generalized peeling skin is one of the manifestations of NTS. We further demonstrate for the first time that NTS may be associated with MRI abnormalities indicative of a permanent tissue injury of the brain.

Nutrition in children with kidney disease: pitfalls of popular assessment methods

Children with chronic kidney disease (CKD) are considered at high risk for protein-energy malnutrition. Clinical practice guidelines generally recommend an evaluation of numerous nutritional parameters to give a complete and accurate picture of nutritional status. This review summarizes the potential limitations of commonly used methods of nutritional assessmentin the setting of CKD. Unrecognized fluid overload and inappropriate normalization of body composition measures are the most important factors leading to misinterpretation of the nutritional assessment in CKD. The importance of expressing body composition measures relative to height or height-age in a population in whom short stature and pubertal delay are highly prevalent is emphasized. The limitations of growth as a marker for nutritional status are also addressed. In addition, the prevailing belief that children with CKD are at high risk for malnutrition is challenged.

Mother-Child touch patterns in infant feeding disorders: relation to maternal, child, and environmental factors

OBJECTIVE

To examine mother and child's touch patterns in infant feeding disorders within a transactional framework.

METHOD

Infants (aged 9-34 months) referred to a community-based clinic were diagnosed with feeding disorders (n = 20) or other primary disorder (n = 27) and were case matched with nonreferred controls (n = 47). Mother-child play and feeding were observed and the home environment was assessed. Microcoding detected touch patterns, response to partner's touch, and proximity at play. Relational behaviors were coded during feeding.

RESULTS

Compared with infants with other primary disorder and case-matched controls, less maternal affectionate, proprioceptive, and unintentional touch was observed in those with feeding disorders. Children with feeding disorders displayed less affectionate touch, more negative touch, and more rejection of the mother's touch. More practical and rejecting maternal responses to the child's touch were observed, and children were positioned more often out of reach of the mothers' arms. Children with feeding disorders exhibited more withdrawal during feeding and the home environment was less optimal. Feeding efficacy was predicted by mother-child touch, reduced maternal depression and intrusiveness, easy infant temperament, and less child withdrawal, controlling for group membership.

CONCLUSIONS

Proximity and touch are especially disturbed in feeding disorders, suggesting fundamental relationship difficulties. Mothers provide less touch that supports growth, and children demonstrate signs of touch aversion. Touch patterns may serve as risk indicators of potential growth failure.

Geriatric failure to thrive

In elderly patients, failure to thrive describes a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments. Manifestations of this condition include weight loss, decreased appetite, poor nutrition, and inactivity. Four syndromes are prevalent and predictive of adverse outcomes in patients with failure to thrive: impaired physical function, malnutrition, depression, and cognitive impairment. Initial assessments should include information on physical and psychologic health, functional ability, socioenvironmental factors, and nutrition. Laboratory and radiologic evaluations initially are limited to a complete blood count, chemistry panel, thyroid-stimulating hormone level, urinalysis, and other studies that are appropriate for an individual patient. A medication review should ensure that side effects or drug interactions are not a contributing factor to failure to thrive. The impact of existing chronic diseases should be assessed. Interventions should be directed toward easily treatable causes of failure to thrive, with the goal of maintaining or improving overall functional status. Physicians should recognize the diagnosis of failure to thrive as a key decision point in the care of an elderly person. The diagnosis should prompt discussion of end-of-life care options to prevent needless interventions that may prolong suffering.

Family, socioeconomic and prenatal factors associated with failure to thrive in the Avon Longitudinal Study of Parents and Children (ALSPAC)

BACKGROUND

The epidemiological profile of infants failing to thrive is unclear. The aim of this study is to investigate the prenatal and socioeconomic factors associated with these infants using standardized weight gain conditional on previous weight.

METHODS

In a large UK population cohort study, 11 718 infants born at term in 1991-1992 with no major congenital abnormalities were identified. Using a weight gain criterion conditional on initial weight from birth to 6-8 weeks, 6-8 weeks to 9 months, and birth to 9 months, the slowest gaining 5% were identified.

RESULTS

None of the prenatal factors was associated with failure to thrive in the multivariable analysis nor were traditional markers of socioeconomic deprivation such as poor parental education or low occupational status. Parental height was significantly correlated with slow infant weight gain in both separate periods and from birth to 9 months (Pearson's r = +0.20, P < 0.001). Eight times as many infants born to shorter parents (8.7%, 95% CI: 6.6, 11.3) showed slow weight gain as infants born to taller parents (1.1%, 95% CI: 0.5, 2.5). Higher parity was also related to slow infant weight gain; infants born in the fourth or subsequent pregnancy were twice as likely to fail to thrive from birth to 9 months (8.3%, 95% CI: 6.4, 10.6) as first-born infants (3.4%, 95% CI: 2.9, 10.6).

CONCLUSIONS

Future studies need to take account of parental height when calculating growth standards and look at why failure to thrive is more common, not in poorer families but in larger families.

On the relative contributions of positive reinforcement and escape extinction in the treatment of food refusal

We compared the effects of positive reinforcement alone, escape extinction alone, and positive reinforcement with escape extinction in the treatment of the food and fluid refusal of 4 children who had been diagnosed with a pediatric feeding disorder. Consumption did not increase when positive reinforcement was implemented alone. By contrast, consumption increased for all participants when escape extinction was implemented, independent of the presence or absence of positive reinforcement. However, the addition of positive reinforcement to escape extinction was associated with beneficial effects (e.g., greater decreases in negative vocalizations and inappropriate behavior) for some participants.

A 5-week-old HIV-1–exposed girl with failure to thrive and diffuse nodular pulmonary infiltrates

A 5-week-old female infant with vertical HIV-1 exposure, progressive cough, and failure to thrive was given a diagnosis of bilateral diffuse nodular lung lesions. The child was without fever, leukocytosis, anemia, peripheral adenopathy, or hepatosplenomegaly, and the results of repeated blood tests for HIV-1 DNA were negative. A needle biopsy of the lungs revealed granulomatous inflammation and giant cells, with fungal organisms suggestive of Aspergillus species. A nitroblue tetrazolium dye test performed on the patient's blood specimen demonstrated absence of dye reduction, suggesting a diagnosis of chronic granulomatous disease. Further analysis revealed that the child had a deficiency of the p47(phox) component of the nicotinamide adenine dinucleotide phosphate oxidase system. Thus this child with vertical HIV-1 exposure and diffuse pulmonary nodules actually had an autosomal recessive form of chronic granulomatous disease. This case study clearly demonstrates that children with suspected HIV-1 infection might also need evaluation for primary immunodeficiency and that the clinical immunology laboratory is a powerful adjunct in coming to a correct diagnosis.

Classical phenotype of Laron syndrome in a girl with a heterozygous mutation and heterozygous polymorphism of the growth hormone receptor gene

We describe here a 19 month-old girl with classical Laron syndrome (LS). Molecular analysis of the GH receptor gene in the patient and her parents was performed. The patient was found to be heterozygous for a mutation in exon 4 (R43X) and heterozygous for a polymorphism in exon 6 (Gly168Gly). Her mother was also heterozygous for R43X but homozygous for the polymorphism. In the father, a heterozygous polymorphism was found. Contrary to previous assumptions that only homozygous patients express the typical phenotype, this patient shows all the classical features of LS, despite being a heterozygote for a pathological defect.