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CHALLENGING CASES: BIOPSYCHOSOCIAL PEDIATRICS Failure to Thrive in a 4-Month-Old Nursing Infant

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CHALLENGING CASES: BIOPSYCHOSOCIAL PEDIATRICS Failure to Thrive in a 4-Month-Old Nursing Infant CHALLENGING CASES: BIOPSYCHOSOCIAL PEDIATRICS Failure to Thrive in a 4-Month-Old Nursing Infant* CASE visits she was observed to respond quickly to visual Christine, a 4-month-old infant, is brought to the and auditory cues. There was no family history of office for a health-supervision visit by her mother, serious diseases. a 30-year-old emergency department nurse. The In that a comprehensive history and physical ex- mother, who is well known to the pediatrician to be amination did not indicate an organic cause, the a competent and attentive caregiver, appears unchar- pediatrician reasoned that the most likely cause of acteristically tired. They are accompanied by the 18- her failure to thrive was an unintentional caloric month-old and 4-year-old siblings because child care deprivation secondary to maternal stress and ex- was unavailable, and her husband has been out of haustion. Christine’s mother and the pediatrician town on business for the last 5 weeks. When the discussed how maternal stress, fatigue, and depres- pediatrician comments, “You look exhausted. It must sion could hinder the let-down reflex and reduce the be really tough to care for 3 young children,” the availability of an adequate milk supply, as well as mother appears relieved that attention was given to make it difficult to maintain regular feeding sessions. her needs. She reports that she has not been getting The pediatrician recommended obtaining help with much sleep because Christine wakes up for 2 or more child care and household responsibilities. The evening feedings and the toddler is now awakening mother was also encouraged to consume adequate at night. During the day, she juggles nursing the fluids, eat high-protein foods, nurse more frequently, baby, caring for her other 2 young children, and and offer a formula supplement after nursing 3 times managing the household. Although visibly fatigued a day. and mildly depressed, the mother appears comfort- At the same time that these therapeutic interven- able holding Christine; the baby likewise appeared tions were initiated, screening laboratory studies closely attached. The mother has no concerns regard- were obtained. All results were normal, including a ing Christine’s health or development. complete blood cell count with differential; serum During the physical examination, Christine is a electrolytes, creatinine, hepatic transaminase (ATL), slightly thin but active and alert infant. She has no total protein, and albumin; urinalysis; and stool fat remarkable or focal physical findings; her muscle stain and occult blood. A serum thyroxine was nor- strength, tone, and reflexes are normal. She achieves mal (6.3 mg/dL). A plan was made for Christine to all motor, social, and language milestones for a return to the office in 1 week. 4-month-old infant. Plotting her height and weight on the growth chart, the pediatrician and mother INDEX TERMS. failure to thrive, breastfeeding, maternal hypo- were surprised to see that her weight did not change thyroidism. in 2 months, and her linear growth decelerated slightly. The growth measurements were repeated and corroborated. In the office, Christine was a vig- Dr Martin T. Stein orous feeder, latching onto the full areola quickly. The biopsychosocial model is an effective guide During the nursing session, she studies her mother’s for pediatricians who care for infants, children, and face, cooed, and reached out for the breast with her adolescents. It is particularly useful during early in- free hand. The mother reports that breastfeeding oc- fancy when faced with a feeding problem. The inter- curs every 4 to 5 hours for at least 10 minutes on each action between physiological functions and psycho- breast. Her urine output and bowel movements are logical factors shapes our clinical thinking when normal, and she did not have a history of vomiting or confronted, in particular, with a nutritional disorder. excessive regurgitation. The mother’s diet and fluid During the early infant period, growth is depen- intake seem adequate. dent on a healthy relationship between a baby and its A review of past medical history does not reveal mother (or caretaker). The quality of attachment be- an explanation for Christine’s failure to gain weight. tween an infant and mother is delineated during an She was born full-term after an uncomplicated preg- observation of a feeding episode. Pediatricians use nancy and a normal spontaneous vaginal delivery. these moments in the office to assess mother-child Her birth weight was 8 pounds. She was nursing attachment and the characteristics of the feeding pro- vigorously by the time of discharge from the hospi- cess. Christine appeared to be nursing adequately; tal. At her 2-week and 2-month health-supervision she demonstrated behaviors that reflect a positive visits, her weight and linear growth and develop- attachment to her mother and appropriate mechanics mental milestones were normal. In addition, at those of nursing. Without historical clues to explain failure to thrive between 2 and 4 months of age, the normal physical examination and the normal breastfeeding * Originally published in J Dev Behav Pediatr. 2002;23:266–270. doi:10.1542/peds.2004-1721N observation left the pediatrician uncertain about the PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Acad- cause for growth deficiency. By systematically incor- emy of Pediatrics and Lippincott Williams & Wilkins. porating biological and psychosocial factors, the out- 1468 PEDIATRICS Vol.Downloaded 114 No. 5 from November www.aappublications.org/news 2004 by guest on September 24, 2021 come in these cases is usually successful with an creases in weight for age and smaller decreases in early intervention. length for age and weight for length than bottle-fed Two pediatricians were invited to comment on this infants when using the NCHS charts. This is because challenging case. Dr Daniel Kessler is a develop- the data sets used to construct these curves had few mental-behavioral pediatrician who is a Clinical As- breastfed infants. This slower increase in weight can sociate Professor of Pediatrics and Director of Devel- be particularly prominent between 3 and 12 months opmental and Behavioral Pediatrics at the Arizona and is of no concern in the otherwise healthy infant.8 Child Study Center, Children’s Health Center of St The revised growth charts2 have a higher proportion Joseph’s Hospital and Medical Center in Phoenix, of breastfed infants than the 1977 charts, and this Arizona. Dr Kessler is coeditor of a recent book of should no longer be a cause for concern. significant value to pediatricians, Failure to Thrive and In contrast with the absence of contributing histor- Pediatric Undernutrition: A Transdisciplinary Approach. ical or physical examination data that might provide Dr Eustratia (“Tia”) Hubbard is a fellow in Devel- a diagnostic clue for an organic cause for Christine’s opmental and Behavioral Pediatrics at the University lack of expected growth, the psychosocial data are of California, San Diego. rich in risk factors. She is the third of 3 children born Martin T. Stein, MD in a 4-year time span, just 14 months younger than Professor of Pediatrics her next-oldest sibling. Christine is still waking for a University of California feeding at least twice a night (a good sign), and now Children’s Hospital San Diego the 18 month old is waking in the night as well. Her San Diego, California mother has been single-parenting for the past 5 Dr Daniel B. Kessler weeks as her husband is away on a business trip. She The case of Christine, a 4-month-old infant with must juggle the needs of her young family and her failure to thrive (or what my colleague Peter Dawson own needs, which often appear last in the equation. and I prefer to call “pediatric undernutrition”1) pre- We are not told of extended family or other environ- sents the primary care provider with a diagnostic mental supports. The mother sounds and looks de- challenge. This child presents with a significant de- pressed. Parental depression, particularly in the pri- celeration in her expected pattern of growth. At the mary caregiver, is a risk factor for inadequate growth 2-month office visit, the history indicates that her in an infant. weight increased from 8 pounds at birth to the 75th In this type of situation, the primary care pediatri- percentile of the National Center for Health Statis- cian has an advantage over his or her specialist col- tics2 (NCHS) growth curves (assuming she had leagues. This is the advantage of relationships devel- maintained this growth percentile). Four-month-old oped over time and a longitudinal perspective. The girls are expected to gain an average of 26 g per day.3 pediatrician was obviously quite comfortable in this Christine did not gain any weight during this time relationship and shared with Christine’s mother the period, and her linear growth showed a deceleration possibility that Christine’s poor weight gain might be as well. Christine is described as otherwise doing a reflection of stress and exhaustion. This informa- well and making expected gains in the developmen- tion was provided supportively and without judg- tal domains assessed. History and physical examina- ment,9 and an appropriate intervention plan was tion as well as basic screening laboratory evaluations provided. In addition, the pediatrician has the luxury are normal. To determine the cause or causes of this to allow the case to evolve over time without ex- growth problem, the primary care provider needs to hausting the diagnostic laboratory and the family carefully review the presenting data to determine with 1 esoteric test after another without appropriate possible risk factors for poor or no growth. indication. Basic screening laboratory tests and oth- Failure to gain weight or pediatric undernutrition ers that might be indicated by a careful history and in the exclusively breastfed infant is somewhat of a physical examination are all that are necessary.10,11 mystery.
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