Symptom-Based Diagnosis in Pediatrics (CHOP Morning Report) 1st Ed.

CASE 6-7

Eighteen-Month-Old Boy

STEPHEN LUDWIG

BRANDON C. KU

HISTORY OF PRESENT ILLNESS

This 18-month-old boy was brought to the emergency department for a chief complaint of draining ear. Once in the emergency department it was noted that he was markedly wasted. Vital signs included a body temperature below normal. Height, weight, and head circumference were below the 3rd percentile. Heart rate was 40 bpm with a respiratory rate of 26 per minute.

The examination of the ears showed bilateral draining otitis media. There was loss of hair that was brittle. There were multiple scabs on the body. The examination was very notable for loss of almost all-subcutaneous tissue (Figure 6-6). There was no reported weigh loss or diarrhea. The mother reported no other symptoms.

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FIGURE 6-6. Picture of the patient with marked failure to thrive.

MEDICAL HISTORY

The child had been born in a healthy condition. The mother was married and living in a suburban community. The child had grown normally for several months but then the mother noted multiple food allergies and placed him on a restrictive diet. She had not sought regular care for the child but frequently sought advice from telephone hotlines and calls to multiple physicians’ offices. The child had lost developmental milestones. The mother and father were both college graduates. There was no smoking or drinking in the house. Both parents admitted to using marijuana on a regular basis.

PHYSICAL EXAMINATION

T 35.9°C; HR 40 bpm; RR 16/min; Weight far below the 5th percentile; Height far below 5th percentile; Head circumference at 10th percentile

In general, the child was a weak-appearing and cachectic male with decreased movement and a weak cry. His hair was stubbled. He had a purulent draining otitis media. There was no adenopathy. The chest was clear. The heart rate was bradycardic with weak pulses. The abdomen was scaphoid with decreased bowel sounds. On the skin, there were multiple marks and scars and hyperpigmented macules in diaper area and diffusely. On neurologic examination, the child was dull, apathetic, and weak. He had decreased muscle mass and muscle tone.

DIAGNOSTIC STUDIES

Hemoglobin, 9.6 mg/dL; serum protein was below normal.

COURSE OF ILLNESS

The hospital course involved treating the ear infection and starting the child on nutritional support and iron. He responded with weight gain and improvement of his development. At the end of 2 weeks in the hospital, he had made tremendous strides in both growth and development. He ate large quantities of food.

DISCUSSION CASE 6-7

DIFFERENTIAL DIAGNOSIS

The severity of the child’s condition prompted the consideration of a wide differential diagnosis. The parent’s economic status and educational level prompted the medical care team to eliminate psychosocial causes. Yet, when confronted with the child’s response to supportive care and feeding and normal laboratory pattern that he demonstrated, a nonorganic etiology for his life-threatening condition was revealed.

DIAGNOSIS

The final diagnosis was weight loss and developmental repression due to psychosocial causes. The diet that the mother selected for the child was too restrictive in content and calories. Her presenting complaint missed the obvious wasting and was a clue to her lack of perception and parenting ability. Parents underwent psychiatric testing and were felt to be unsuitable caretakers. The child recovered completely and was discharged to a foster home (Figure 6-7).

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FIGURE 6-7. Picture of the child 16 months later.

INCIDENCE AND EPIDEMIOLOGY OF PSYCHOSOCIAL CAUSES

The true incidence of psychosocial failure to thrive is not known. Many case series of children with failure to thrive (FTT) show that 40%-80% is due to psychosocial causes or a combination of psychosocial and medical causes (so-called mixed FTT). The epidemiology is varied and can result from postpartum depression, a lack of knowledge about parenting, or more overt child abuse and willful starvation. It is difficult to sort through the motivation of the parents, yet the results in the child are obvious and disturbing.

CLINICAL PRESENTATION

Clinical presentations are varied from children who have minor falling off on their growth parameters to cases of death by starvation. Serial measures of length or height, weight, and head circumference are helpful in sorting through the causes and in differentiating psychosocial and medical etiology.

DIAGNOSTIC APPROACH

Diagnostic approach is best assessed by the signs and symptoms the child manifests. Without special symptoms, it is best to feed the child in a controlled setting and monitor the weight gain. There is no single battery of laboratory tests to be recommended. Some that may be helpful include CBC (iron-deficient anemia), urinalysis (UTI, RTA), and PPD for tuberculosis. HIV infection may also be a cause for failure to thrive. Skeletal survey for trauma may be indicated if there is suspicion of abuse.

TREATMENT

The treatment for nonorganic failure to thrive requires close follow-up and a multidisciplinary approach to meeting the needs of the child and the family. In some cases, the child will need to be removed from the care of the parents until a system of care and follow-up can be proposed. In this case, a foster home was used initially and then the child returned under close (weekly) supervision. Subsequently, a physical abuse episode caused long-term removal of the child. Usually nutritional recovery time will equal the length of time that the organic deprivation occurred.

SUGGESTED READINGS

1. Ludwig S. Failure-to-thrive and starvation. In: Ludwig S, Kornberg A, eds. Child Abuse and Neglect: A Medical Reference. 2nd ed. New York: Churchill-Livingstone; 1992.

2. Altemeier WA, O’Connor SM, Sherrod KB, et al. Prospective study of antecedents for nonorganic failure-to-thrive. J Pediatr. 1985;106:360.

3. Frank DA, Drotar D, Cook J, et al. Failure to thrive. In: Reece R, Ludwig S, eds. Child Abuse: Medical Diagnosis and Management. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2001.