Swanson – Failure to Thrive and Short Stature

An 8-month-old infant is brought to the emergency department by his mother for an assessment of an upper respiratory tract infection. He has been coughing for the past 3 days and has had a runny nose. On examination, his temperature is 37.5° C. His weight is below the third percentile for his age, his length is at the 25th percentile, and his head circumference is at the 50th percentile. He appears malnourished and has thin extremities, a narrow face, prominent ribs, and wasted buttocks. He has a prominent diaper rash, unwashed skin, a rash that resembles the skin infection impetigo contagiosa on his face, uncut fingernails, and dirty clothing.

1. What is the most likely diagnosis in the infant described? This child most likely has nonorganic FTT secondary to child e. Approximately 90% of FTT is nonorganic in origin.

2. What is the most likely cause of this child’s condition? maternal deprivation FTT may be a result of organic causes, nonorganic causes, or both. Nonorganic causes predominate. Nonorganic FTT includes psychological FTT (maternal deprivation), child neglect, lack of education regarding feeding, and errors in feeding. Nonorganic FTT is most often attributable to maternal deprivation (as in this case) or lack of a nurturing environment at home. Organic FTT is caused most commonly by a medical condition impairing the child’s ability to take in, to absorb, or to metabolize adequate calories.

3. What is (are) the procedure(s) of choice for this infant at this time? The treatment of choice at this time is to hospitalize the child and to give unlimited feedings for a minimum period of 1 week. At the same time, a careful physical examination and laboratory investigations including CBC, complete urinalysis, renal function testing, and serum TSH level can be completed. If the child lives in an inner-city neighborhood with older housing stock, a serum lead level test should also be done. The family physician should involve social services and also initiate a detailed assessment of the child’s home environment. Before the child is discharged home, the home environment must be assessed and the parents of the child must be given explicit instructions in feeding practices.

3. Where is follow-up of this child best performed? in the home by the public health nurse If the child begins to gain weight rapidly and to reestablish his health in the hospital (which is very likely), reassessment ideally should be done in the environment that allowed the development of the problem in the first place (at least on some occasions). This is obviously the home, and the health care professional in the best position to do this is probably the public health nurse or the community health nurse.

5. The initial follow-up plan suggests the frequency of visits for the child to be which of the following? every week The initial follow-up supervision should be close and frequent—every week for the first 6 weeks after discharge from the hospital is reasonable.

6. The environment that exists for this child should be thoroughly assessed for which of the following? Maternal neglect resulting in nonorganic FTT should not be just left at that; the reasons need to be investigated. A mother who neglects her child (a form of child abuse) is also at risk for committing other forms of child abuse. In addition, she is at greater than average risk of being abused by her husband or partner. Remember that family violence begets family violence, and in this case, we already have established that a form of family violence (child abuse [neglect]) exists.

A 9-month-old infant comes in for a routine examination and immunizations. The infant has fallen off  the previous percentile  line.  The  patient’s  mother has an eighth-grade education, lives on state support, and has not identified the  father  of  the  child. On questioning, the mother indicates that she has been living with her parents but has been told she must find a place of her own. She exhibits signs of depression.

Examination shows an infant with no physical anomalies but whose weight is  disproportionate  to his height and has fallen off the curve set in the first 9 months.

1. There is a strong relationship of this child’s diagnosis to which of the following? family stress According to recent research, there is no clear relation between weight faltering and maternal deprivation, educational level, or markers of eating disorders.

2. As assistance is provided for the mother for the depression and financial challenges, the infant will: catch up with his peers by the age of 1 year Evidence indicates that infants of mothers with depression and stress are more than twice as likely to have FTT symptoms but are no different from their peers by the age of 1 year. Only occasionally infants will have developed problem eating behaviors and will benefit from behavioral intervention even as the mother is treated.

3. Which of the following investigations should be performed for a child with FTT or a child for whom short stature is unlikely to be familial in nature? Recommended investigations in a child with FTT or a child in whom short stature is unlikely to be familial in nature should include CBC, complete urinalysis, serum BUN and creatinine, erythrocyte sedimentation rate (ESR), serum thyroxine, TSH, and bone age hand radiograph. Serum lead level, stool for ova and parasites, and liver enzymes (serum bilirubin, alanine aminotransferase, and aspartate aminotransferase) may be considered when the clinical history is suggestive.
   • complete blood count (CBC)
   • complete urinalysis
   • serum blood urea nitrogen (BUN) and creatinine
   • T₄ and thyroid-stimulating hormone (TSH)

A 13-year-old girl is brought to your office for assessment of her short stature. On examination, the child has height and weight below the fifth percentile, a webbed neck, lack of breast bud development, high-arched palate, and low-set posterior hairline.

1. What is the most likely diagnosis in this child? Turner syndrome The most likely cause of this child’s short stature is Turner syndrome. Noonan syndrome (an autosomal dominant trait with a widely variable pattern of expression) also has short stature and neck webbing as its most common presentation. It can be distinguished from Turner syndrome easily, however, by its normal chromosome complement and characteristic facies including hypertelorism and ptosis.
   Patients with Turner syndrome will have either a 45 XO chromosome complement or a mosaic involving loss of sex chromosomal material. Trisomy 21 will usually be recognized long before the age of 13 years. The fragile X syndrome is associated with mental retardation and macroorchidism in males.

2. What is the most common cause of short stature in children? familial short stature The most common cause of short stature in children is short parents. When a short child who is growing at a normal rate and has a normal bone age is found to have a strong family history of short stature, familial short stature is the most likely cause. Other causes of short stature include constitutional delay of growth, chromosomal abnormalities, intrauterine growth restriction, chronic diseases such as renal disease or inflammatory bowel disease, hypothyroidism, adrenal hyperplasia, growth hormone deficiency or resistance, psychosocial dwarfism, and idiopathic short stature.

3. Bone age can sometimes be used to differentiate certain causes of short stature in With respect to bone age, which of the following statements is true? bone age is normal in familial short stature and delayed in constitutional delay of growth b. Bone age determination can distinguish between the two most common causes of short stature: familial short stature and constitutional delay of growth. Children with familial short stature have normal bone ages. Constitutional delay of growth, which is really a delay in reaching ultimate height and sexual maturation, is manifested by delayed bone age and signs of sexual maturation. Hypothyroidism and growth hormone deficiency usually are manifested with a delayed bone age.

4. Psychosocial dwarfism is a situation in which poor physical growth may be associated with an unfavorable psychosocial With respect to psychosocial dwarfism, which of the following statements is (are) true? d. Inadequate growth in children may be associated with an unfavorable psychological environment. In this situation, the child may show transiently low human growth hormone levels during periods of stress. He or she may also have behavioral, sleep, and eating disturbances. Both growth and growth hormone levels return to normal when the psychological stressors are removed.
   • sleep and eating aberrations occur in these children
   • growth usually returns to normal when the stress is removed
   • behavioral problems are common in these children

4. List at least 10 disorders that may be manifested as FTT in infants and children. Disorders that may be manifested as FTT in infants and children include the following: (1) emotional/psychological factors, (2) central nervous system abnormality, (3) gastrointestinal malformation (pyloric stenosis, tracheoesophageal fistula, and cleft palate) or dis ease (Hirschsprung disease, gastroesophageal reflux, chronic diarrheal syndromes and malabsorption diseases, inflammatory bowel disease, liver disease, or parasites), (4) congenital or acquired heart disease (cardiac failure), (5) chronic renal disease (anomalies and renal failure), (6) chromosomal disorders (Down syndrome and Turner syndrome), (7) chronic infection (gastrointestinal system, kidney, pulmonary system, central nervous system, tuberculosis, human immunodeficiency virus infection, and hepatitis), (8) inborn error of metabolism (hypothyroidism, hyperthyroidism, and hyperaldosteronism), (9) malignant neoplasms (neuroblastoma, nephroblastoma, and glioma), (10) anemias, (11) congenital low-birth-weight syndrome (fetal alcohol or drug exposure), (12) cystic fibrosis, (13) bronchopulmonary dysplasia, and (14) drug reactions.