Failure to Thrive or Growth Faltering: Medical, Developmental/Behavioral, Nutritional, and Social Dimensions

Progressive Thrombocytopenia, Splenomegaly, and Abnormal Tone in an Infant With Growth Faltering

A 4-month-old full-term female presented with growth faltering associated with progressive feeding difficulty, rash, abdominal distension, and developmental delays. She was found to have disconjugate gaze, abnormal visual tracking, mixed tone, bruising, and splenomegaly on examination. Initial workup was notable for thrombocytopenia and positive cytomegalovirus (CMV) immunoglobulin G and immunoglobulin M antibodies. She initially presented to the infectious diseases CMV clinic, where she was noted to have severe malnutrition, prompting referral to the emergency department for hospital admission to optimize nutrition with nasogastric tube feeding and facilitate additional evaluation. An active CMV infection with viruria and viremia was confirmed, but elements of her presentation and workup including brain magnetic resonance imaging were not consistent with isolated CMV infection. To avoid premature diagnostic closure, a multidisciplinary workup was initiated and ultimately established her diagnosis.

A 15-Month-Old with Faltering Growth

AbstractMorning Report is a time-honored tradition where physicians-in-training present cases to their colleagues and clinical experts to collaboratively examine an interesting patient presentation. The Morning Report section seeks to carry on this tradition by presenting a patient's chief concern and story, inviting the reader to develop a differential diagnosis and discover the diagnosis alongside the authors of the case. This report examines the story of a 15-month-old with faltering growth and short stature. Using questions, physical examination, and testing, an illness script for the presentation emerges. As the clinical course progresses, the differential is refined until a diagnosis is made.

Strategies to Promote Success in Oral Feedings in Infants and Children with Intestinal Failure due to Short Bowel Syndrome

Infants and children with intestinal failure are at risk for pediatric feeding disorders, which challenge their oral feeding development. This article explores these challenges and offers several practical strategies that can be used by multidisciplinary care teams and at-home caregivers to help support the development of oral feeding in these children and eventually lead to their attaining enteral autonomy.

Electrical Stimulation of Acupuncture Points Helps Resolve a Child's Failure to Thrive

Background

Failure to thrive (FTT) is a challenging childhood condition that may lead to developmental delays and requires immediate therapeutic strategies. Children are diagnosed with FTT when their weight or rate of weight gain is significantly below that of other children of similar age and sex. A Pub Med literature search revealed no published acupuncture treatments for failure to thrive or faltering growth.

Case

A 2 year, 4 month-old female was presented with FTT and a history of multiple severe congenital medical conditions. Western medical treatment with optimization of tube feeds achieved weight scores in the third-to-fifth percentile range. Acupuncture points were electrically stimulated for the child once monthly for 30 seconds with a Pointer Plus™ at each of 12 traditional Chinese/Shu Mu points and at several auricular points: Appetite, Stomach, Small Intestine, and Large Intestine bilateral.

Results

The patient gained weight during the treatment, increasing monthly as shown on fully naked weight measurements to the 25th percentile, 28th percentile, 32nd percentile, 40th percentile, 46th percentile, 61st percentile, and 65th percentile. Her treatment was spaced to every 2.5 months after the 46th percentile measurement, and her weight started to level off when it reached the 61st percentile.

Conclusions

In this particular case, electroacupuncture (EA) stimulation may have facilitated a weight gain in this female child. EA (nonneedle) research should be explored for FTT.

Successful management of pylorospasm with atropine in a failure-to-thrive neonate case report

Pylorospasm is an elusive diagnosis that can mimic the presentation of pyloric stenosis. There is limited discussion regarding its management in neonates with few case reports describing the use of antispasmodic agents. The following case reviews this management in a unique neonate. A 2-month-old female presented with persistent nonbilious, nonbloody emesis and failure-to-thrive. A thorough workup was performed due to its pronounced persistence while inpatient. Pyloric ultrasounds remained negative for pyloric stenosis; however, an upper gastrointestinal (GI) study was significant for pylorospasm. The workup also revealed hypothyroidism. Antispasmodic therapy with atropine was pursued as she was not a surgical candidate. Patient tolerated IV atropine therapy well with quick resolution of emesis and successfully transitioned to oral atropine therapy, displaying continued weight gain with exclusive oral feeds. This case displays a unique presentation of pylorospasm with successful management utilizing IV and oral atropine therapy in a neonate with failure-to-thrive and concomitant hypothyroidism.

Disparities in the Diagnosis and Management of Infants Hospitalized With Inadequate Weight Gain

OBJECTIVES

To evaluate the association between race and the named etiology for inadequate weight gain among hospitalized infants and assess the differences in management.

METHODS

This single-center retrospective cohort study of infants hospitalized for the workup and management of inadequate weight gain used infant race and neighborhood-level socioeconomic deprivation as exposures. The etiology of inadequate weight gain was categorized as nonorganic, subjective organic (ie, gastroesophageal reflux and cow's milk protein intolerance), or objective organic (eg, hypothyroidism). The management of inadequate weight gain was examined in secondary outcomes.

RESULTS

Among 380 infants, most were white and had a nonorganic etiology of inadequate weight gain. Black infants had 2.3 times higher unadjusted odds (95% credible interval [CI] 1.17-4.76) of a nonorganic etiology of inadequate weight gain compared with white infants. After adjustment, there was no association between race and etiology (adjusted odds ratio 0.8, 95% CI [0.44-2.08]); however, each 0.1 increase in neighborhood-level deprivation was associated with 80% increased adjusted odds of a nonorganic etiology of inadequate weight gain (95% CI [1.37-2.4]). Infants with a nonorganic etiology of inadequate weight gain were more likely to have social work and child protective service involvement and less likely to have nasogastric tube placement, gastroenterology consults, and speech therapy consults.

CONCLUSIONS

Infants from neighborhoods with greater socioeconomic deprivation were more likely to have nonorganic causes of inadequate weight gain, disproportionately affecting infants of Black race. A nonorganic etiology was associated with a higher likelihood of social interventions and a lower likelihood of medical interventions.

Prospective Associations between Maternal Depressive Symptoms during Early Infancy and Growth Deficiency from Childhood to Adolescence

Maternal health represents an important predictor of child development; yet it often goes unnoticed during pediatric visits. Previous work suggests that mental state affects parenting. The relationship between infant exposure to maternal depressive symptoms suggests conflicting findings on physical growth. Body mass index (BMI) has not been rigorously examined across development. Using a prospective-longitudinal birth cohort of 2120 infants (50.7% boys), we estimated the prospective relationship between symptoms of maternal depressive symptoms at 5 months postpartum and later BMI in typically developing children. We hypothesized that maternal depressive symptom severity would predict later BMI through to adolescence. Mothers self-reported depressive symptoms at 5 months. Child BMI was measured by a trained research assistant at ages 6, 8, 10, 13, and 15 years. We estimated a series of sex-stratified regressions in which BMI was linearly regressed on maternal symptoms, while controlling for potential pre-existing/concurrent individual and family confounding factors. Boys born to mothers with more severe depressive symptoms at age 5 months had a significantly lower BMI than other boys at subsequent ages. There were no such associations observed for girls. Maternal depressive symptoms were prospectively associated with later BMI for sons and not daughters, predicting risk of faltering in growth through to adolescence. Health practitioners should routinely assess maternal psychological functioning during pediatric visits to optimize parent and child flourishment.

Etiologies of Poor Weight Gain and Ultimate Diagnosis in Children Admitted for Growth Faltering

BACKGROUND AND OBJECTIVES

Growth faltering (GF) (previously failure to thrive) is a common reason for hospital admission, but there is little data on whether diagnoses made during initial admission remain accurate in follow-up. We sought to characterize infants admitted for isolated GF and identify diagnoses at discharge and ultimate diagnoses determined over 2 years of follow-up, to determine how diagnoses changed. We also sought to identify patient factors on admission associated with ultimate diagnosis.

METHODS

We conducted a retrospective study of children aged 2 weeks to 2 years with index admissions for GF from 2013 to 2017. We reviewed clinical data and documentation to determine discharge and ultimate diagnosis, and identify factors associated with ultimate diagnosis.

RESULTS

Of 497 patients, 292 (59%) had insufficient intake, 103 (20%) had organic disease including 36 genetic disorders, 52 (11%) had mechanical feeding difficulties, and 50 (10%) had mixed or unknown diagnoses 2 years after admission. Over 90% of cases of insufficient intake were diagnosed during admission. Sixty-five percent of organic diseases, and only 39% of genetic disorders, were diagnosed during admission. Patient factors associated with genetic disorders included previous NICU stay, low birth weight, dysphagia, hypotonia, and dysmorphisms.

CONCLUSIONS

Insufficient intake remains the most common diagnosis, and this diagnosis was accurately made during admission. Organic disease, especially genetic disease, was often not diagnosed during admission. Better tools are needed to identify patients with organic disease. We identified patient factors on admission associated with ultimate diagnosis, which could be used to prioritize evaluation and expedite follow-up.

New insights in pediatrics in 2021: choices in allergy and immunology, critical care, endocrinology, gastroenterology, genetics, haematology, infectious diseases, neonatology, neurology, nutrition, palliative care, respiratory tract illnesses and telemedicine

In this review, we report the developments across pediatric subspecialties that have been published in the Italian Journal of Pediatrics in 2021. We highlight advances in allergy and immunology, critical care, endocrinology, gastroenterology, genetics, hematology, infectious diseases, neonatology, neurology, nutrition, palliative care, respiratory tract illnesses and telemedicine.