[Adiponecrosis subcutanea neonatorum in congenital pneumonia]

In the course of a connatal pneumonia, a 7-day-old female newborn developed symmetrical subcutaneous nodules on her back, shoulders, and upper arms. These skin lesions were accompanied by hypercalcemia. Histological examination confirmed the putative clinical diagnosis of subcutaneous fat necrosis of the newborn. We discuss the differential diagnoses, therapeutic strategies, and prognosis of this uncommon disorder of the fat tissue.

Failure to Thrive in a 14-Month-Old Boy with Lymphopenia and Eosinophilia

We describe the case of a 14-month-old boy with delayed-onset SCID due to ADA-deficiency which was masqueraded only by failure to thrive. Remarkably, the child had no serious infections and an adequate immune response. However, absolute lymphopenia, eosinophilia and absent thymus on chest x-ray were indicative for immunodeficiency.

Diagnosing cystic fibrosis--asthma and failure to thrive as indications for a sweat test

Children with asthma or failure to thrive (FTT) are frequently referred for the quantitative pilocarpine iontophoresis sweat test (QPIT) for diagnosing cystic fibrosis (CF). The aim of our study was to compare the prevalences of asthma and FTT among patients with a confirmed diagnosis of CF. Two-hundred and fifty-five children, who were referred for QPIT between 1991-1996 in order to rule out CF were studied retrospectively. All sweat samples had been obtained and analyzed according to the National Committee For Clinical Laboratory Standards. Asthma was defined as 24 episodes of wheezing, treated successfully by inhaled bronchodilators. Failure to thrive was was defined by either a weight below the 5th precentile or crossing of 2 major precentiles in 1 year. The prevalence of asthma was significantly higher than that of FTT among the cohort study (28.6% vs. 7.1% as a single indication, and 36.5% vs. 7.9% when combined with other indications). The prevalence of CF among patients with FTT was higher than among asthmatic patients (5.2% vs. 3%, p = 0.06). Not one patient diagnosed as having CF was referred to a sweat test only because of asthma. As a single presentation, the diagnostic yield of asthma seems to be poor, compared to FTT. However, further, larger-scale studies should be conducted on this issue.

Failure to thrive

Failure to thrive is a condition commonly seen by primary care physicians. Prompt diagnosis and intervention are important for preventing malnutrition and developmental sequelae. Medical and social factors often contribute to failure to thrive. Either extreme of parental attention (neglect or hypervigilance) can lead to failure to thrive. About 25 percent of normal infants will shift to a lower growth percentile in the first two years of life and then follow that percentile; this should not be diagnosed as failure to thrive. Infants with Down syndrome, intrauterine growth retardation, or premature birth follow different growth patterns than normal infants. Many infants with failure to thrive are not identified unless careful attention is paid to plotting growth parameters at routine checkups. A thorough history is the best guide to establishing the etiology of the failure to thrive and directing further evaluation and management. All children with failure to thrive need additional calories for catch-up growth (typically 150 percent of the caloric requirement for their expected, not actual, weight). Few need laboratory evaluation. Hospitalization is rarely required and is indicated only for severe failure to thrive and for those whose safety is a concern. A multidisciplinary approach is recommended when failure to thrive persists despite intervention or when it is severe.

Response to the FNB Supplement on the Positive Deviance Approach to Improve Health Outcomes

Food and nutrition policy activities directed toward improvement of the nutritional status of the people of Bangladesh began in the 1980s. The government formulated a national food and nutrition policy and approved it in 1997. Qualitative methods, including observational techniques, in-depth interviews of the key informants, and focus group discussions, were used to collect information on the strengths, weaknesses, opportunities, and threats (SWOT) of the policy. The information obtained has been transcribed and analyzed using this model. The strengths of the policy are that it is a consensus document that emphasizes human rights, was formulated by a multisectoral approach, complements other government policies, and has broad goals and wide-ranging objectives. The weaknesses include lack of implementation, monitoring, and evaluation guidelines; lack of strong government commitment; inadequate support of policy makers; perhaps an excessively ambitious target; and ignorance of past lessons learned. The opportunities include the scope of social mobilization, the wide scope of the policy, suggested programs and measures to improve nutritional status, a congenial policy environment, and the ability to modify the scope of the policy as needed. The threats to the policy are lack of knowledge of the policy, lack of resources to implement the policy, tension between technical people and bureaucrats, vested business interests, and, possibly, discontinuity of political commitment. The key to reducing the weaknesses of the food and nutrition policy of Bangladesh and minimizing the threats to it is for the stakeholders in the policy to coordinate efforts to use the strengths and opportunities of the policy to effectively implement it.

Identifying and managing faltering growth

Five per cent of under-5s will have an episode of faltering growth. 'We need to identify and support these children to prevent problems later' said Sue Barraclough. If unchecked, faltering growth can lead to stunting and delayed development. Many factors contribute to growth faltering, as shown in Figure C. Signs to look out for are listed in Table A.

Functional analysis of inappropriate mealtime behaviors

The purpose of the current investigation was to apply the functional analysis described by Iwata, Dorsey, Slifer, Bauman, and Richman (1982/1994) to the inappropriate mealtime behaviors of 15 children who had been referred to an intensive program for the assessment and treatment of severe feeding disorders. During Study 1, we conducted descriptive assessments of children and parents during meals. The results of Study 1 showed that parents used the following consequences for inappropriate mealtime behaviors: coaxing and reprimanding, allowing the child to periodically take a break from or avoid eating, and giving the child preferred food or toys following inappropriate behavior. The effects of these consequences were tested systematically in Study 2 when we conducted analogue functional analyses with the children. During alternating meals, one of the consequences typically used by parents consistently followed inappropriate child behavior. Results indicated that these consequences actually worsened behavior for 10 of the 15 children (67%). These results suggested that the analogue functional analysis described by Iwata et al. may be useful in identifying the environmental events that play a role in feeding disorders.

[Failure to thrive among hospitalized 0-2 year-old children]

INTRODUCTION

Failure to thrive, defined as insufficient weight gain according to age, is a well-known condition among infants and toddlers. The aim of the study was to investigate the prevalence of diagnosed failure to thrive and possible comorbidity in hospitalised 0-2 year-old children in the County of Copenhagen.

MATERIAL AND METHODS

It resulted from inquiries sent to all paediatric departments in Denmark that the most frequently used ICD-10 diagnoses for failure to thrive were R62.8, E64.9, and E34.3. Data concerning patients with these three diagnoses hospitalised in two paediatric departments in the County of Copenhagen during a two-year period were drawn from the Patient Registry System. The following parameters were registered: sex, age, diagnoses, hospitalizations, and address.

RESULTS

Among referred children below the age of two years, 173 or 4% were diagnosed with failure to thrive. Girls were in excess, the ratio girls-boys being 107:66. More than half, 60% were below one year of age, 40% were below six months of age. We found equal distribution of index children from municipalities with low and high incomes. The diagnosis R62.8 was found in 170 patients, of whom 155 had the diagnosis as either main diagnosis or side diagnosis. Out of these 155 patients 46% had additional somatic diagnosis, whereas 5% had child psychiatric comorbidity.

DISCUSSION

Failure to thrive was diagnosed in 4% of hospitalised children under two years of age. Nearly half of the children diagnosed with failure to thrive had a comorbid somatic diagnosis, whereas only a few was diagnosed with psychiatric or social disturbances.

[Psychosomatic failure-to-thrive in infants and toddlers]

Failure to thrive is found in 3-5% of infants in the general population. A minority has an organic explanation. Non-organic failure to thrive is associated with increased risk of physical illness, continued growth retardation as well as cognitive and emotional disturbances. Non-organic failure to thrive has traditionally been regarded as a maternal deprivation syndrome, but in recent population studies there has been found no evidence of mother-infant relationship disturbances as the main cause of non-organic failure to thrive is the general population. Non-organic failure to thrive is best characterised as a psychosomatic condition with multifactorial etiology. Development and course of failure to thrive has to be explored in longitudinal population studies with prospectively gathered data concerning the perinatal period and first year of life.

Vallecular cyst: a cause of failure to thrive in an infant

Congenital vallecular cyst is fairly uncommon in neonates and infants. Although benign in nature, it may cause stridor and even life-threatening airway obstruction in early infancy. A 3-month-old male baby presented with failure to thrive and respiratory distress was found to have a vallecular cyst. Marsupialization with CO(2) laser was performed.

Impact of feeding problems on nutritional intake and growth: Oxford Feeding Study II

Poor nutritional status and growth failure are common in children with cerebral palsy (CP). The aim of this study was to assess, within a subgroup of a large and clearly defined population of children with disabilities, the impact of feeding difficulties on (1) the quality (micronutrient intake) and quantity (macronutrient intake) of their diet and (2) their growth. One hundred children with disabilities (40 females, 60 males; mean age 9 years, SD 2 years 5 months; range 4 years 6 months to 13 years 7 months) underwent a detailed dietetic analysis and a comprehensive anthropometric assessment. Diagnostic categories of disability were: CP (n=90); global developmental delay (n=3); Marfan syndrome (n=1); intractable epilepsy (n=2); agenesis of the corpus callosum (n=2); methyl malonic aciduria (n=1); and congenital rubella (n=1). Neurological impairment was classified according to difficulty with mobility which was graded as mild (little or no difficulty walking), moderate (difficulty walking but does not need aids or a helper), and severe (needs aids and/or a helper or cannot walk). Results confirmed the significant impact of neurological impairment in children on body growth and nutritional status becoming worse in those with a greater degree of motor impairment. The major nutritional deficit was in energy intake, with only one fifth reportedly regularly achieving over 100% estimated average requirement (EAR), whilst micronutrient intake was less markedly impaired and protein intake was normal in this group (96% above EAR). Many children with neurological impairment would benefit from individual nutritional assessment and management as part of their overall care.

Disease severity at time of referral for pediatric failure to thrive and obesity: time for a paradigm shift?

The percent of ideal body weight at first visit to pediatric referral clinics was compared by chart review between patients with failure to thrive and obese patients. Results indicated that underweight children were mildly underweight, whereas the overweight children were severely so. In primary care settings, underweight children may be referred more aggressively than overweight children.

Growth and failure to thrive

Monitoring of growth in early life is particularly important as growth is elastic and sensitive to environmental factors, especially nutrition. Deficits are unlikely to be recovered fully in a later period and early growth patterns contribute to many diseases of adulthood. Assessment of rate of growth, rather than attained size, is possible with today's charts and accurate measurement. Growth monitoring is important for recognition of failure to thrive and it is valuable as a proxy measure for wellbeing. Many factors can contribute to failure to thrive which is best managed using a multidisciplinary approach.

Feeding disorders in infants and toddlers: diagnosis and treatment

Each of the six feeding disorders described presents with specific symptoms, has a different origin, and responds to different interventions. Consequently, it is important to establish an accurate diagnosis and use the appropriate intervention for the specific feeding disorder. As the study by Benoit et al [7] demonstrates, an intervention that may be helpful for one feeding disorder can be completely ineffective for another.

The syndrome of chronic recurrent multifocal osteomyelitis and congenital dyserythropoietic anaemia. Report of a new family and a review

A new autosomal recessive syndrome of chronic recurrent multifocal osteomyelitis (CRMO) and congenital dyserythropoietic anaemia (CDA) with microcytosis has recently been described in four children (two sibships) of one consangineous Arab family. In this report, we describe the clinical features and course of the syndrome of CRMO and CDA in two additional patients (one sibship) from another consanguineous Arab family and review the literature. The two patients (brother and sister), the products of a consanguineous marriage, developed the syndrome at an early age of 3 weeks and 2 months respectively. The diagnosis of CRMO was confirmed by radiological and technetium isotope bone scans. Bone marrow studies confirmed the diagnosis of CDA. Peripheral blood films showed hypochromia and microcytosis. The sites involved by CRMO were periarticular, mainly around the elbow, knee, wrist and small joints of the hand. The brother is now 21 years old and the sister 3.5 years old and CRMO is still active with frequent relapses. The brother developed flexion deformities at the age of 13 years. Both patients failed to thrive; weight and height were below the 5th percentile.

CONCLUSION

This is the second report of the syndrome of chronic recurrent multifocal osteomyelitis and microcytic congenital dyserythropoietic anaemia, confirming it as a clinical entity, inherited as an autosomal recessive trait. The disease is characterised by an early onset, long clinical course of remissions and relapses, and seems to be different from the sporadic form of chronic recurrent multifocal osteomyelitis.

Omenn's syndrome: differential diagnosis in infants with erythroderma and immunodeficiency

The clinical differential diagnosis of erythroderma plus immunodeficiency and failure to thrive in neonates includes graft-versus-host-disease (GVHD), Omenn's syndrome (OS), and Netherton's syndrome (NS). In addition to immunological investigations, skin biopsy is an important part of the diagnostic work-up. We reviewed biopsies from 25 patients that were retrieved from the archives of the Department of Histopathology at Great Ormond Street, of which 9 were OS, 11 were GVHD, and 5 were NS. Five patients had two biopsy specimens. Both OS and GVHD show dyskeratosis and basal vacuolation. OS always shows acanthosis and almost always parakeratosis. GVHD shows a flat epidermis and rarely parakeratosis. OS and GVHD can be distinguished after immunohistochemistry for LCA and CD68 by the relative proportions of lymphocytes and macrophages in the dermal infiltrate (predominantly lymphocytes in OS, relatively more macrophages in GVHD). Skin biopsy diagnosis of OS is difficult before 6 weeks of age because the features are poorly developed. NS can be distinguished by psoriasiform acanthosis, thickening of the basement membrane, prominent dermal blood vessels, absence of dyskeratosis, and basal layer vacuolation, and a dermal infiltrate in which lymphocytes and macrophages are equally represented. Thus, the main difference between GVHD and OS is in the proportion of lymphocytes and macrophages in the infiltrate on immunohistochemical staining for LCA and CD68, while OS and NS may be distinguished on H&E morphology alone.

Prevention of breastfeeding tragedies

Although successful breastfeeding confers compelling advantages to infants and mothers, inadequate breastfeeding can result in critical infant failure-to-thrive and hypernatremic dehydration. Potential catastrophic infant outcomes can occur when enthusiastic promotion of breastfeeding outpaces necessary support services and management. Such cases often involve underlying maternal and infant breastfeeding risk factors, made deadly by parental and professional misconceptions and knowledge deficits or health care system failures. An early follow-up visit a few days after discharge allows at-risk infants to be identified before they lose excessive weight and at a time when intervention can easily correct most breastfeeding problems before they become complicated by insufficient milk. Those who enthusiastically promote breastfeeding for its many health benefits must confront the reality of breastfeeding failure and implement necessary changes in medical education and support services to foster successful outcomes in breastfed infants.

Generalized seborrheic dermatitis in an immunodeficient newborn

We report the case of a female infant with failure to thrive, generalized seborrheic dermatitis, and intermittent diarrhea. Results of laboratory investigation revealed low serum immunoglobulin G IgG levels. She failed to gain additional weight and experienced recurrent infection. She died 3 months later.

[From functional decline to the slipping syndrome]

Normal aging is accompanied by functional decline with a loss of independence in activities of daily living. In many cases, after acute medical events, such a functional decline is observed, for which rehabilitation therapies are indicated. However, uncommon types of functional decline are also seen, without trigger event, having a particuliar clinical course: some of these are described in this paper, ranging from the "failure to thrive" to the dramatic "slipping syndrome".

[Feeding disorders and failure to thrive in small and/or handicapped children]

Feeding disorders and failure-to-thrive (prevalence 2% to 4%) rarely have an isolated cause, but most often a number of inappropriate conditions are leading up to the development and, especially, the maintenance of the disorder. These can include organic causes like chronic diseases, peculiarities of the person, strange behavior of the child or the care person or of the interaction-problems. An obligatory classification of feeding disorders does not exist. Feeding disorders and failure-to-thrive can ask for a long-term additional or full tube-feeding or the child rejects age-appropriate food texture, has a very selective eating behavior or there are massive interaction problems during feeding. Feeding disorders and failure-to-thrive can not only have direct physical effects but also long-term unfavourable influences on behavioral aspects as well as on mental abilities. The diagnosis of feeding disorders and failure-to-thrive comprises next to the clarification of a basic organic disease, the clarification of swallowing and oral-motor capabilities as well as the exclusion of a gastroesophageal reflux. A differentiated feeding protocol must include the oral feeding as well as the tube feeding. A behavior observation comprises the feeding situation and, if necessary, further situations of interaction. Besides the treatment of the basic disease, a direct guidance in the feeding situation for the care person is necessary. Furthermore, a therapy of the oral motorics as well as one of the care person and guidelines for interaction during different situations can be important.

Structural airway anomalies in patients with DiGeorge syndrome: a current review

DiGeorge Syndrome is a genetic disorder characterized by either absence or hypoplasia of the thymus and the parathyroid glands. Patients with this syndrome also have a high incidence of cardiovascular malformations and facial dysmorphism. Structural airway anomalies have also been described, albeit infrequently. Tracheoesophageal fistula, short trachea with reduced numbers of tracheal rings, abnormal thyroid cartilage, laryngomalacia, tracheomalacia, and bronchomalacia have been recognized in these patients. We review all previously reported patients with DiGeorge syndrome and lower airway anomalies. In addition, we present 2 patients with DiGeorge syndrome who were each found to have an aberrant right tracheal bronchus. Structural airway anomalies can be a cause of morbidity and mortality in patients with DiGeorge syndrome. Prompt, thorough evaluation of the upper and lower airway in these patients is essential.

Anthropometric indices of failure to thrive

AIMS

To compare five anthropometric methods of classifying failure to thrive in order to ascertain their relative merits in predicting developmental, dietary, and eating problems.

METHODS

The five anthropometric methods were compared in 83 children with failure to thrive.

RESULTS

The methods were inconsistent in classification of severity, and no one method was superior in predicting problems.

CONCLUSIONS

Weight alone, being the simplest, is still the most reasonable marker for failure to thrive and associated problems.

Patient with insufficient glandular tissue experiences milk supply increase attributed to progesterone treatment for luteal phase defect

A case report is presented on the experience of a mother diagnosed with insufficient glandular tissue at 3 months postpartum with her first child who then went on to breastfeed her second child (fifth pregnancy) without supplementation of any kind. The mother had difficulty becoming pregnant and maintaining a pregnancy. She was diagnosed with a luteal phase defect and was thus treated with natural progesterone during her fifth pregnancy. The authors speculate that this treatment may have stimulated the development of her mammary alveolar cells, allowing lactation to progress normally.

[Psychosocially stunted growth masked as growth hormone deficiency]

Short stature is a common reason for presenting a child to the pediatrician. Emotional deprivation may cause short stature and may simulate growth hormone deficiency. Diagnosis of emotional deprivation as the cause of growth retardation is difficult and misdiagnosed frequently despite of suspicious clinical signs. We report on 2 patients with growth retardation because of emotional deprivation. At the age of 5 years both children had a severe growth hormone deficiency. They received therapy with growth hormone and showed an increase of growth velocity to > or = 8 cm in the first year of treatment. But in the third year of treatment both patients showed a diminished response to the growth hormone therapy. During the period of observation the features of emotional deprivation became obvious through the extreme behavioural abnormalities. Both children showed disturbances in their social behaviour, and striking disorders concerning eating and digestion. The families of these children had severe social problems; alcoholism, low income and rejection of the child were risk factors. Removal from the current environment led to a characteristic increase of the growth velocity. Growth hormone deficiency was spontaneously reversible, so that treatment with growth hormone was terminated. The social environment and the psychical prosperity are essential growth factors in childhood and adolescence. The common features and risk factors of emotional deprivation are described. Spontaneous catch-up growth after removal from the current environment distinguishes this form of short stature from the other organic growth disorders.

Genetic analysis of the G4.5 gene in families with suspected Barth syndrome

Mutations have recently been identified in the G4.5 gene (Xq28), encoding the tafazzin protein, in patients with Barth syndrome. We performed mutational analysis in 5 families with suspected Barth syndrome. In 4 families a male child had all the cardinal features of this syndrome, and mutations of G4.5 were found in each case. A mutation was also found in a fifth family with an extensive history of early infant death from heart disease. The recognition of 5 unrelated families in 1 hospital during a 7-year period suggests that this disease may be underdiagnosed.

Failure to grow

Failure to grow in pups and kittens can be the result of many factors. Dietary, metabolic, endocrine, parasitic, neoplastic, and genetic diseases may be responsible for a failure to thrive alone or in concert with other disorders. A complete history, physical examination, complete blood cell count, biochemistry profile, and urinalysis are the initial steps to define the underlying disorder(s). Subsequent tests may be needed based on these initial diagnostic results.

Fading kitten syndrome and neonatal isoerythrolysis

Fading kitten syndrome includes noninfectious and infectious causes for neonatal death (birth to weaning age). Noninfectious causes are mostly responsible for mortality in the first week of life and include congenital disorders, low birth weights, trauma, malnutrition, environmental causes, and neonatal isoerythroylsis. Infectious causes are more prevalent at 3-4 weeks of age. This article discusses the causes, clinical signs, and management of fading kitten syndrome.

Slow weight gain and low milk supply in the breastfeeding dyad

There are a large number of women who perceive a reduction in milk supply. With appropriate, knowledgeable advice, most are able to continue breastfeeding successfully. If an infant is not gaining weight normally, the mother's milk production must be assumed to be low (usually a secondary phenomenon); meanwhile, consider the possibility of an organic problem in mother or infant. The complex interactional nature of the problem requires attention to history, physical examination, differential diagnosis, and thoughtful problem solving. There are situations that require infant supplementation for optimal growth; when this is the case, supplementation should be provided in a way that best supports continued breastfeeding to the fullest extent possible. Anticipatory guidance, early detection of problems, and prompt intervention are the keys to ensuring copious milk production and normal infant growth.

Medical assessment. Its role in comprehensive psychiatric evaluation

This article describes the role of a medical evaluation in the overall developmental assessment of a young child. General guidelines for conducting the evaluation and practical issues to consider in dealing with young children and their families are provided. To illustrate these points, hypotonia and failure to thrive, two broad categories of pathology with numerous potential underlying medical causes, are addressed specifically. The involvement of genetics in developmental pathology is also outlined in some detail. Finally, issues to be aware of when considering pharmacologic management of psychiatric symptoms in young children are discussed.

Oral-motor dysfunction in children who fail to thrive: organic or non-organic?

Forty-seven children with non-organic failure to thrive (NOFT) were identified from a whole-population survey of children's growth and development. A significant proportion (N=17) of these 47 children were found to have oral-motor dysfunction (OMD) identified using a previously validated assessment tool. NOFT children with OMD and those with normal oral-motor function (N=30) were compared in order to ascertain whether there were any neurodevelopmental differences which might explain this finding. We hypothesized that children with OMD might have a subtle neurodevelopmental disorder. Few psychosocial variables discriminated the two groups. However, cognitive stimulation within the home and cognitive-growth fostering during mealtimes was much poorer for children with OMD. Some evidence has suggested that NOFT children with OMD may be 'biologically' more vulnerable from birth. We suggest that the continued use of the term 'non-organic' to describe failure to thrive in such children is questionable and requires redefining.