[Williams-Beuren syndrome in combination with celiac disease]

At age 5 years coeliac disease was diagnosed in a boy with Williams-Beuren syndrome. Gastrointestinal symptoms may be similar in both disorders. Short stature, not only in comparison to the normal population but also in comparison to syndrome-specific growth standards, and failure to thrive led to the diagnosis coeliac disease. During the first year of dietetic therapy the boy showed marked weight gain, catch-up growth and a normalisation of red blood count. Gliadin-IgG antibodies and endomysium-IgA antibodies who were positive before treatment were no longer detectable. Our case demonstrates that syndrome-specific growth standards are helpful even though the combination of Williams-Beuren syndrome with a second disorder is very unlikely (Williams-Beuren syndrome and coeliac disease are to be expected in 1:13.7-1:25 millions).

Elder care. A diagnostic model for failure to thrive

1. Care of the elderly is often complicated by complex, interacting conditions. Major areas of concern for the elderly are malnutrition, depression, and confusion (in the form of dementia or delirium). Malnutrition has been prevalent in both hospitalized and institutionalized elderly. 2. Failure to thrive (FTT) has long been recognized in pediatric patients as a multifaceted syndrome that is primarily a disorder of nutritional status and physical and mental development. The characteristics of FTT in the elderly are undernutrition, loss of physical and cognitive function, and depression. 3. The redefinition and alteration of terms from the infant model of FTT results in three categories of FTT in the elderly--psychosocial, predisposing, and physical, as opposed to the two categories of FTT in infants--the infant and the environment.

Mevalonic aciduria in 3 siblings: a new recognizable metabolic encephalopathy

Mevalonic aciduria, due to mevalonate kinase deficiency, is the first recognized defect in the biosynthesis of cholesterol and isoprenoids. Very few patients with this disorder have been reported. Three siblings born from consanguineous parents are reported. Several clinical signs were present in all 3 children, including failure-to-thrive, susceptibility to infections, hepatosplenomegaly, cataract, and psychomotor retardation. Dysmorphic features were more apparent in the two older siblings. Urinary organic acid analysis by gas chromatography/mass spectrometry invariably revealed a high urinary excretion rate of mevalonic acid. Mevalonate kinase activity assayed in fibroblasts was very low. Diagnosis of this very rare disease may be suspected simply on clinical evidence; it is confirmed by abnormal excretion of mevalonic acid.

Familial white matter hypoplasia, agenesis of the corpus callosum, mental retardation and growth deficiency: a new distinctive syndrome

We have observed in two different families two pairs of male siblings born from normal, non-consanguineous parents having the same syndrome, characterized by severe cerebral white matter hypoplasia, agenesis or extreme hypoplasia of the corpus callosum, mental retardation, failure to thrive and minor midline facial abnormalities. This seems to be a previously unreported genetic syndrome.

[Dystrophy caused by upper airway obstruction]

We describe three infants whose main symptoms were poor weight gain, delayed motor development and recurrent respiratory infections. Obstructive sleep apnea was diagnosed, and all three improved after adenotomy or adenotonsillectomy. Obstructive sleep apnea is an important differential diagnosis in infants showing retarded development and failure to thrive.

Decreased serum bicarbonate as a manifestation of undernutrition secondary to nonorganic failure-to-thrive

Eight of 101 children (8%) seen serially in consultation in an outpatient failure-to-thrive (FTT) clinic had isolated serum bicarbonate (TCO2) levels between 16 and 20 MEQ/dL (normal 22 to 30 MEQ/dL). None of these eight patients had signs or symptoms of renal disease, and all had nonorganic etiologic factors associated with their malnutrition. At the time of this review, follow-up TCO2 measurements were available for seven of the eight children who had attained normal weight (wt/age greater than fifth percentile on National Center for Health Statistics (NCHS) growth chart). All these children had normal TCO2 levels and no evidence of renal disease on follow-up more than 12 months later. Clinicians treating undernourished children who have low TCO2 measurements and have no signs or symptoms of renal disease and identified nonorganic factors, should consider a trial of therapies directed at nonorganic factors. Clinicians should be aware that a high percentage of undernourished children without other medical disease may have abnormal TCO2 measurements that correct after the institution of adequate caloric intake.

Ineffective suckling: a possible consequence of obstructive positioning

Failure to thrive in breastfed babies frequently is attributed to inadequate lactation. In some cases, the origin of inadequate lactation may be ineffective suckling that obstructs milk flow. To support this conclusion, an infant who presented with failure to thrive was studied at the breast with magnetic resonance imaging.

Infantile depression, nonorganic failure to thrive, and DSM-III-R: a different perspective

A controversy exists regarding the classification of nonorganic failure to thrive within the psychiatric nomenclature. There are a number of DSM-III-R diagnoses that may be applied to NOFTT, including Reactive Attachment Disorder of Infancy (RADI) and Major Depressive Disorder (MDD). The behaviors characteristic of NOFTT are symptomatic of depression, and are similar to those exhibited by infants with anaclitic depression as well as those of the adult with depression. The correspondence of the behaviors of NOFTT and the DSM-III-R criteria for Major Depression are reviewed, as are the conceptual and therapeutic reasons to view NOFTT infants as suffering from Depression.

Disturbances of affect expression in failure-to-thrive

Positive and negative affects were assessed in 28 6- to 36-month-old children with failure-to-thrive and 14 normally growing children in feeding and nonfeeding situations. The roles of malnutrition and severity of organic effects also were examined. Failure-to-thrive children expressed less positive affect in the feeding and nonfeeding situations and more negative affect in feeding than normally growing children. Among failure-to-thrive children, the presence of both acute and chronic malnutrition was associated with heightened negative affect during feeding, whereas the degree of organic contribution had no effect. These results, if replicated, may have implications for clinical assessment and are discussed in terms of current theories of failure-to-thrive.

[Diagnosis and therapy of early mother-child disorder, the so-called failure to thrive in the infant]

Feeding baby's is mostly a gratifying activity for mothers. But when difficulties arise, they can develop into a serious pediatric issue: The so-called non organic failure to thrive (NOFT). In these cases the feeding difficulties are one aspect of the disturbed relation between the mother and her child. Conventional pediatric therapy often fails to achieve weight gain, the babies seem emotionally disturbed and upset during all feeding procedures. Phenomenologically oriented documentation of the quality and type of the diadic interactions allow a diagnosis of the relationship itself and cleans up with terms like "unreliable" mother or "difficult" babies. We present the first review of theoretical background, diagnostic nomenclature and therapeutic concepts in german and wish to address colleagues with a interest in psychotherapeutic methods.

A neurobehavioral syndrome after failure to thrive on chloride-deficient formula

Eleven of 13 children, who demonstrated a failure-to-thrive pattern in infancy attributable to chloride-deficient Neo-Mull-Soy formula, had distinctive cognitive impairments four to nine years later. These included: a language disorder primarily involving articulation, word finding and naming; visual-motor and fine motor difficulties; and attention deficit disorder, often featuring repetitive behaviours, withdrawal and perseveration ('overfocus'). In contrast, global intellectual abilities were within the normal range in all 11 children. This residual neurobehavioral syndrome is too rare in the developmentally disabled population to reflect a chance association. It has not been associated either with protein-calorie malnutrition or chloride-deficiency diseases.

Recognising failure to thrive in early childhood

The maximum weight centile achieved by a child between 4 and 8 weeks of age was found to be a better predictor of the centile at 12 months than the birth weight centile. Children whose weight deviated two or more major centiles below this maximum weight centile for a month or more showed significant anthropometric differences during the second year of life from those who showed no such deviation. It is suggested that this leads to a logical and practical definition of failure to thrive.

Munchausen syndrome by proxy presenting as a developmental disability

Munchausen syndrome by proxy (MSBP) is a form of child abuse in which a parent falsifies illness in a child by fabricating or producing symptoms and presenting the child for medical care while disclaiming knowledge as to the cause of the problem. This report presents the case history of a child diagnosed with MSBP who was portrayed as having multiple developmental disabilities by her mother. Three elements of the case are noteworthy. The emphasis by the mother on multiple developmental disabilities has not been reported. The complexity of this case is unusual and may reflect the complexity of the mother's psychopathology. The interdisciplinary team evaluation was instrumental in making the diagnosis.

'Failure to thrive' in the elderly: diagnosis and management

"Failure to thrive" (FTT) is a term used to describe a gradual decline in physical and/or cognitive function of an elderly patient, usually accompanied by weight loss and social withdrawal, that occurs without immediate explanation. Both age-related and sociodemographic factors predispose the elderly to FTT. The most common etiologies are dementia, depression, delirium, drug reactions, and a few chronic diseases. The diagnostic evaluation of patients with FTT includes a review of the patient's activities of daily living, cognitive function, and mood; a targeted history and physical examination; and selected laboratory studies. Early recognition and management of FTT can reduce the risk of further functional deterioration, hospitalization, or nursing home placement.

Wiedemann-Rautenstrauch syndrome

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Sampling issues in research with nonorganic failure-to-thrive children

Describes the methodological problems posed by sampling characteristics of nonorganic failure-to-thrive (NOFT) children and strategies to address them. Sources of variance in sample characteristics include the criteria used to define NOFT, populations from which samples are drawn, parent refusal and sample attrition, medical and psychological treatment, and individual differences in environmental or biologic risk factors. Undesirable consequences of unrecognized intrasample variation in NOFT include sample bias, limited generalizability of findings across different settings, and erroneous assumption of sample homogeneity. Comprehensive description of sample selection and characteristics will enhance more accurate definition of NOFT, generalizability of findings, and evaluation of the impact of sampling characteristics. Future studies should focus on objective assessment of subtypes of NOFT and the relationship of individual difference variables to psychological status and prognosis.

Mid-arm circumference and mid-arm circumference: head circumference ratio for assessing longitudinal growth in hospitalized preterm infants

In order to study the usefulness of upper mid-arm circumference (MAC) and mid-arm circumference:head circumference ratio (MAC:HC) measurements in assessing longitudinal growth in hospitalized preterm infants, we prospectively measured weights, lengths, occipitofrontal head circumferences (OFC), MACs, MAC:HCs, weight/length for age, nutritional intakes, and serum transthyretin and albumin levels in 50 preterm, low-birth-weight, appropriate for gestational age newborn infants during their first 4 postnatal weeks and at hospital discharge. At some time during hospitalization, weight measurements were abnormal (greater than or equal to 2SD from the gestational age mean) in 48% of the infants as compared with 24% with abnormal MAC measurements (p = 0.002). Abnormal MAC:HCs occurred in 25% of the infants as compared with 68% with abnormal weight/length for age values (p less than 0.001). During weeks 2-4, when nutritional intakes were adequate and serum transthyretin and albumin levels were normal, mean weight gain velocity was less than intrauterine rates and was significantly slower than MAC velocities, which were at or greater than intrauterine rates (p less than 0.001). At discharge, when all infants were gaining weight at intrauterine rates, weight measurements were still abnormal in 28% of the infants as compared with 10% of infants who had abnormal MACs (p = 0.005). Similarly, only 12% of infants had abnormal MAC:HCs as compared with 25% of infants with abnormal weight/length for age values at discharge (p = 0.05). The MAC and MAC:HC are useful for assessing longitudinal growth in preterm infants since they do not overestimate the prevalence of malnourishment during periods of apparent protein-calorie sufficiency.

Occult pulmonary artery associated with failure to thrive and recurrent pneumonia--a case report

Occult pulmonary artery is an uncommon cardiovascular defect. Associated symptoms include recurrent pulmonary infections and congestive heart failure. The authors describe a one-year-old boy initially diagnosed as having broncho-pulmonary dysplasia who developed severe failure to thrive, recurrent pneumonias, and pulmonary hypertension. The presence of an occult right pulmonary artery was suspected by lung perfusion scan and diagnosed by cardiac catheterization and angiography. After surgical repair, his clinical course improved and his growth and development were normal. This case demonstrates the importance of including occult pulmonary artery in the differential diagnosis of infants with failure to thrive associated with recurrent pulmonary infection.

[Treatment of the child with growth retardation (failure to thrive)]

This paper presents a multidisciplinary approach to treat children with failure to thrive (FTT). The FTT team of the Instituto Costarricense de Investigación y Enseñanza en Nutrición y Salud (INCIENSA) is composed of professional staff, including pediatrician, nutritionist, psychologist and social worker. They evaluate each patient and provide an integrated treatment. The early detection and the appropriate management of children with FTT will improve the physical and psychosocial condition of these patients.

Gastroesophageal reflux in infants and children

Seventy-five infants and children presenting during the period December 1984 to December, 1987 with the clinical features of vomiting, failure to thrive, chronic cough, recurrent pneumonia and atypical asthma were evaluated for gastroesophageal reflux by standard barium esophagram. Fifty six cases (74.7%) and as many as 80% of the infants studied had gastroesophageal reflux; Grade II reflux was seen in 12 cases, Grade III in 30 and Grade IV in 14 cases. The patients with gastroesophageal reflux were put on medical treatment. All the patients had subjective improvement after 6 weeks to 6 months of conservative treatment and none of them developed further complications of gastroesophageal reflux during a follow-up period varying from two months to fifteen months. Anti-reflux surgery was not considered owing to the subjective improvement in all the patients on conservative treatment. We conclude that gastroesophageal reflux is very common in infants and children and urge the need to evaluate the patients presenting with the symptoms suggesting gastroesophageal reflux by barium esophagram; conservative treatment is the mainstay in the management of these children.

Gastrostomy dependence in two constitutionally short children

We describe the medical odyssey of two infants who turned out to be constitutionally short. The measurements of length gradually came to rank below the fifth percentile during the first 18 months of life. Numerous tests were performed, and the diagnosis of gastroesophageal reflux led to fundoplication. The concept that higher energy intakes result in greater increases in length led eventually to gastrostomy. Increases in weight during gastrostomy feedings had no effect on growth in length. It was very difficult to convince the parents that the gastrostomies were not necessary. The parents had in fact become "gastrostomy dependent." The vague concept of "failure to thrive" proved to be misleading and obscured the knowledge that constitutionally short children can fall below the fifth percentile in length at any time before the age of 2 or 3 years.

Immediate prenatal diagnosis of Zellweger syndrome by direct measurement of very long chain fatty acids in chorionic villus cells

We report a gas chromatographic-mass spectrometric method which allows the very long chain fatty acids content of trophoblastic tissue to be directly measured in samples collected by biopsy between 8 and 11 weeks of gestation. This method has been successfully applied to the detection of fetal Zellweger syndrome in two pregnant women who had previously delivered affected infants. In one of them, increased concentrations of C26:0 (0.254 versus 0.108 +/- 0.035 microgram/mg proteins) and C24:0 (1.32 versus 0.815 +/- 0.325 microgram/mg proteins) in trophoblast indicated that the fetus had Zellweger syndrome, a diagnosis confirmed by pathological findings after abortion. In the second case, the pregnancy was allowed to proceed, on the basis of normal concentrations of very long chain fatty acids in trophoblastic tissue, and its outcome was actually a healthy newborn.

Plasma carnitine deficiency. Clinical observations in 51 pediatric patients

We studied the clinical spectrum associated with secondary plasma carnitine deficiency in 51 pediatric patients. Forty-three patients had total plasma carnitine values below 20 mumol/L and an additional eight patients had total values above 20 mumol/L but had low free plasma carnitine levels. The clinical presentation in the patients with total plasma carnitine deficiency included hypotonia (34 of 43), failure to thrive (27 of 43), recurrent infections (27 of 43), encephalopathy (six of 43), nonketotic hypoglycemia (seven of 43), and cardiomyopathy (nine of 43). Of the eight patients with low free and elevated esterified carnitine levels, the signs and symptoms at presentation included hypotonia (six of eight), recurrent infections (six of eight), failure to thrive (six of eight), encephalopathy (three of eight), nonketotic hypoglycemia (one of eight), and cardiomyopathy (one of eight). All patients were treated with L-carnitine. Treatment time varied from one month to 24 months (average, four months). A subjective improvement in muscle tone was seen in 24 of 38 patients, 22 of 33 patients showed acceleration of incremental growth, and infection frequency appeared to decrease in 18 of 33 patients. After therapy, the echocardiograms of all patients with cardiomyopathy normalized. There were no further hypoglycemic episodes. Of the nine patients with encephalopathy, eight showed improvement in their mental status. Three patients died of complications of their primary disorder. In our experience, secondary plasma carnitine deficiency is a common pediatric finding. The presence of failure to thrive, recurrent infections, hypotonia, encephalopathy, cardiomyopathy, or nonketotic hypoglycemia requires investigation of carnitine status.

Abnormal sweat electrolytes in a case of celiac disease and a case of psychosocial failure to thrive. Review of other reported causes

Sweat electrolytes were initially elevated in a child who was diagnosed as having celiac disease and also in one with psychosocial failure to thrive. Subsequent sweat tests were normal after nutritional status of the patients had improved with therapy. The reports of elevated sweat electrolytes in conditions other than cystic fibrosis are discussed. It is emphasized that sweat test methods other than the quantitative pilocarpine iontophoresis method are not reliable. The occurrence of false-positive sweat tests demonstrates the need for care in the interpretation of elevated sweat electrolytes and the necessity of performing repeat quantitative pilocarpine iontophoresis for the establishment of the diagnosis of CF. Celiac disease and malnutrition from other causes may cause sweat electrolytes to be elevated.

Behavior as a diagnostic aid in failure-to-thrive

The presence of a defined set of behaviors was examined in 67 hospitalized infants, 3-24 months old; 17 with organic failure-to-thrive (OFTT), 17 with nonorganic failure-to-thrive (NOFTT), and 33 with no signs of failure-to-thrive. The usefulness of assessing these behaviors to distinguish nonorganic from organic failure-to-thrive infants was evaluated. The frequency of behaviors per infant as well as the intensity of behaviors was greater for NOFTT. The order of decreasing frequency of behaviors was similar in both OFTT and NOFTT infants. Four of the 7 most prevalent behaviors occurred significantly more frequently in NOFTT than OFTT infants. The presence of these behaviors does not rule in NOFTT or rule out OFTT. However, when a number of the behaviors are present, particularly if they occur in high intensity, and when no organic disease is found, a diagnosis of NOFTT is suggested. Response to appropriate treatment remains the most reliable confirmation of the diagnosis.

An occupational therapy protocol for assessing infants and toddlers who fail to thrive

Children who "fail to thrive" are frequently referred to occupational therapists. Yet there is no organized protocol that therapists could use to assess these children. This paper reviews criteria that distinguish organic from nonorganic "failure to thrive" and describes the occupational therapist's contribution to the evaluation process. An occupational therapy protocol is presented to facilitate a thorough assessment, emphasizing feeding issues and caretaker-child interaction.

Deciduous tooth eruption in children who fail to gain weight

In order to investigate the usefulness of the number of erupted deciduous teeth (NET) as a growth parameter, we studied deciduous tooth eruption (DTE) in 46 infants between the ages of 6 and 30 months, who failed to gain weight. The cause of the failure to thrive was intrauterine growth retardation in 17 children, and undetermined in 29. In these babies, height and head circumference were significantly below the mean as well. However, NET was almost unchanged when compared to NET of Israeli children of the same age. These findings support the view that DTE is an independent process, unrelated to other anthropometric measurements. Thus, NET may not be used as a clinical parameter of physical development.

Failure to thrive in the perinatal period

Identification of newborn nutritional inadequacy is one of the major areas in perinatal medicine where intervention can influence outcome. An infant's failure to thrive may be the result of prenatal and/or post-natal causes. Management of failure to thrive in the newborn infant must include identification of the problem, establishment of an efficient therapeutic regimen and means of evaluating the morbidity which may occur.

Non-organic failure to thrive: a reappraisal

Non-organic failure to thrive has traditionally been regarded as due primarily to maternal rejection and neglect. A critical reappraisal of the evidence suggests a more balanced view of the mother-child relationship should be taken. A classification of the condition, founded on facts not concepts, is urgently required. Non-organic failure to thrive should be viewed in a multidimensional context, in which potential influences upon the symptomatic infant are considered. Inadequacy of nutrition is caused by both a failure of adequate provision of food and by inadequate intake. A vicious circle of maladaptive behavioural interaction between caregiver and infant is often present, sustained by high emotional tensions. Clinical intervention should aim to clarify the contributions made by both caregiver and infant to that interaction and thus break the cycle. The basis on which intervention is made should be direct observation of the parent and child relationship in as many different environmental contexts as feasible, especially during feeding. The multidisciplinary team has an important role to play in management. An emphasis on parental culpability in the aetiology of non-organic failure to thrive, in the absence of direct evidence of neglect, is wrong.

Management of children with failure to thrive in a rural ambulatory setting. Epidemiology and growth outcomes

To evaluate the growth course of children with failure to thrive (FTT) who receive aggressive management, we reviewed the 2-year experience of a secondary level ambulatory diagnostic and management clinic for children with FTT in a mostly rural state. We examined the children managed in this setting for cause of FTT, for growth outcomes after 1 year according to FTT clinical type, and for differentiating predisposing sociodemographic information Of 154 children referred to this clinic, 131 were diagnosed as suffering from FTT. Eighteen were admitted to the hospital after initial outpatient evaluation, and 93 were followed for at least 1 year. Twenty-two (17%) suffered from organic, 59 (45%) non-organic, and 46 (35%) mixed etiology FTT. After 1 year, 48 (52%) of the FTT children were improved, 37 (40%) were stable, and 8 (9%) were worse. Children placed in foster care were more likely to be improved (78%). FTT children considered improved after 1 year demonstrated the following at the time of initial diagnosis: lower maternal income, lower maternal education, and lower family socioeconomic status; higher birth order; more often black; and less likely for the father to be present in the home (all p less than or equal to .05). This experience offers several insights into the growth course and team management of FTT children.