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 depressed. 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. In a mature, experienced mother, lactation This approach does not come naturally to the inex- difficulties would be unexpected.4 Passive, undemanding infants may fuss less and consume less than perienced clinician who must face his or her own the required amount of calories needed for growth in anxiety when faced with a complex dilemma. The this rapid growth phase of infancy. Feeding at 4- to need for diagnostic certainty in the face of little sup- 5-hour intervals may be a little long for Christine to portive evidence is seductive. Nevertheless, the abil- go between nursing. Undernutrition in this time ity to “embrace complexity” to avoid premature di- frame in a breastfed infant has also been associated agnostic closure, to allow information to develop, with a significant amount of underlying illness in the and to consider new information carefully as it be- infant5 or in the mother.6 So far there is no evidence comes available is a valuable trait and one worthy of for either. practice. Had Christine’s weight gain been slow rather than absent, it may have been helpful to review her Daniel B. Kessler, MD Clinical Associate Professor of Pediatrics weight using a growth chart for exclusively breastfed Director, Developmental and Behavioral Pediatrics infants. Several studies have found that breastfed Arizona Child Study Center infants follow a different growth trajectory than Children’s Health Center of St Joseph’s Hospital and what the 1977 NCHS growth charts indicate.7 Exclu- Medical Center sively breastfed infants can show significant de- Phoenix, Arizona

Downloaded from www.aappublications.org/news by guest on September 24, 2021 SUPPLEMENT 1469 REFERENCES In turn, infrequent breastfeeding decreases milk pro- 1. Kessler DB, Dawson P, eds. Failure to Thrive and Pediatric Undernutrition: duction secondary to dysregulation of prolactin-in- A Transdisciplinary Approach. Baltimore, MD: Paul H. Brookes Publish- duced lactation. ing Co; 1999 It is important for the pediatrician to inquire about 2. Centers for Disease Control and Prevention, National Center for Health a mother’s well-being during these early visits to Statistics. 2000 CDC growth charts: United States. Available at: www.cdc.gov/growthcharts. Accessed April 23, 2002 assess for fatigue, social stressors, and psychological 3. Guo S, Roche AF, Fomon SJ, et al. Reference data on gains in weight and disturbances. As many as 30% to 75% of mothers length during the first two years of life. J Pediatr. 1991;119:355–362 may experience “postpartum blues,” a transient con- 4. Wight NE. Management of common breastfeeding issues. Pediatr Clin dition with onset in the first few weeks after delivery North Am. 2001;48:321–344 5. Lukefahr JL. Underlying illness associated with failure to thrive in and characterized by sadness, tearfulness, and dys- 1 breast-fed infants. Clin Pediatr (Phila). 1990;29:468–470 phoria. Adequate rest, optimal nutrition, and extra 6. Deacon JD. Failure to thrive in the contented breast-fed baby [letter]. support at home are helpful; specific therapy is not CMAJ. 1985;132:97–100 usually necessary. In contrast, postpartum depres- 7. Dewey KG, Peerson JM, Brown KH, et al. Growth of breast-fed infants sion is manifested by irritability, fatigue, anorexia (or deviates from current reference data: a pooled analysis of US, Canadian and European data sets. Pediatrics. 1995;96:495–503 less often overeating), early morning awakening, and 8. Dewey KG. Nutrition, growth, and complementary feeding of the decreased libido and may develop in 10% to 15% of breastfed infant. Pediatr Clin North Am. 2001;48:87–104 women. A severe depression may progress to in- 9. Sturm L, Dawson P. Working with families: an overview for providers. clude suicidal ideation and, in approximately 1 to 2 In: Kessler DB, Dawson P, eds. Failure to Thrive and Pediatric Under- 1,2 nutrition: A Transdisciplinary Approach. Baltimore, MD: Paul H. Brookes per 1000 mothers, psychosis. Antidepressant phar- Publishing Co; 1999 macotherapy is often indicated along with support- 10. Kessler DB. Medical evaluation of the poorly growing child. In: Bitho- ive care and, in some cases, psychotherapy. ney W, Wright J, eds. Pediatric Nutritional Challenge: From Undernutrition Pediatricians are in the position of identifying to Overnutrition. Columbus, OH: Abbott Laboratories, Ross Products early signs of postpartum depression because they Division; 1997:2–13 11. Rider EA, Bithoney WG. Medical assessment and management and the are often the only health care providers to have organization of medical services. In: Kessler DB, Dawson P, eds. Failure contact with a mother in the first 6 weeks. If a mother to Thrive and Pediatric Undernutrition: A Transdisciplinary Approach. Bal- appears to be suffering from this condition, immedi- timore, MD: Paul H. Brookes Publishing Co; 1999 ate referral to her physician or a mental health specialist is warranted. If untreated, postpartum depres- Interim History sion will interfere with mother-infant attachment, At the first follow-up visit, Christine’s weight had infant care, the child’s development, and family increased 1.2 ounces per day in response to more functioning. Maternal depression also places a child frequent nursing and formula supplementation. She at increased risk of emotional and physical neglect, returned to the pediatric office the following week physical abuse, language delays, and poor socializa- for another weight check and again showed gains. tion. In this case, Christine’s mother experienced a What was more interesting was the information her low-grade depression of organic origin that re- mother shared at this visit. The mother’s sister, a sponded to thyroxine hormone replacement. Several second-year medical student visiting from another studies indicate that postpartum thyroid dysfunc- state, noticed that her sister had a “puffy” face and tion, especially in the presence of thyroid antibodies, suggested the possibility of a “hormone imbalance.” may place a mother at increased risk for depres- Christine’s mother made an appointment with her sion.3–5 In addition, postpartum depression may be doctor, who made a prompt biochemical diagnosis of more likely to occur in women with antithyroid an- Hashimoto’s thyroiditis (hypothyroid phase). Soon tibodies even in the absence of hypothyroidism.4 after thyroid replacement was initiated, Christine’s Is it also possible that postpartum hypothyroidism mother had more energy, was more animated, and may impair adequate lactation? The literature on this produced a greater volume of breast milk, allowing topic is sparse unless you are a cow! Studies of dairy her to gradually wean with the formula supplemen- cows have shown that induced maternal hypothy- tation. Christine experienced catch-up growth and roidism leads to decreased milk production and poor continued to grow and develop normally. weight gain in their euthyroid calves; this trend is reversed by thyroxine hormone replacement.6 A Dr Eustratia Hubbard lower fat content of milk has also been found in Failure to thrive as a result of psychosocial factors hypothyroid dairy cows. In a human study among is far more common in the United States than that of hypothyroid mothers, significantly less breast milk organic origin. However, in Christine’s case, both was produced during the first 6 days postpartum psychosocial and maternal medical factors played a compared with control mothers, even when euthy- role in her poor weight gain. Her mother developed roidism was attained with thyroxine therapy.7 When clinical evidence of hypothyroidism due to autoim- a mother has difficulty with adequate breast milk mune thyroiditis during the postpartum period with production, the diagnosis of maternal hypothyroid- symptoms of fatigue, depressed mood, and myx- ism should be considered after other recommenda- edema. Maternal exhaustion may be expected during tions are not successful, such as increasing frequency the first few weeks after delivery, especially if there of breastfeedings, ensuring adequate fluid and ca- are other young children to attend to and a lack of loric intake, and nursing in a quiet, comfortable place additional caregivers. Inadequate rest may interfere to help facilitate milk let-down. with a mother’s ability to consistently meet the needs Once Christine’s mother began thyroid-hormone of her young infant, including routine breastfeeding. replacement, her breast milk production increased

1470 FAILURE TO THRIVEDownloaded IN A from 4-MONTH-OLD www.aappublications.org/news NURSING INFANT by guest on September 24, 2021 and the infant’s growth and development were nor- 11. Muller AF, Drexhage HA, Berghout A. Postpartum thyroiditis and mal; however, it remains uncertain whether Chris- autoimmune thyroiditis in women of childbearing age: recent insights and consequences for antenatal and postnatal care. Endocr Rev. 2001;22: tine escaped unharmed from this episode. Her 605–630 mother may have had thyroid dysfunction during pregnancy as well. Increasing evidence indicates that Web Site Discussion hypothyroidism in pregnant women is associated The case summary for the Challenging Case was with subtle intellectual impairment in their children. posted on the Developmental and Behavioral Pedi- More specifically, hypothyroxinemia in the first tri- atrics Web site‡ (www.dppeds.org.list) and the Jour- mester places a fetus at an increased risk for abnor- nal’s Web site (www.lww.com/DBP). Comments mal neuropsychological development.8,9 This may were solicited. even occur with normal triiodothyronine and thyroid-stimulating hormone levels because maternal Dipesh Navsaria, MPH, Physician Assistant/Medical T4 is the sole fetal source of thyroid hormone during Student, University of Illinois, Champaign the first trimester. The presence of maternal thyroid I had a similar case to this last year in which a peroxidase antibodies during pregnancy has also 4-month-old nursing infant stopped gaining weight been associated with a 10-point lower IQ in off- and even began to slowly lose weight. After a nega- spring, adding to the evidence that low thyroid re- tive laboratory evaluation and repeated weight serve as a result of autoimmune thyroiditis may have checks, I asked a question that I probably should adverse effects during fetal life.11 have asked more clearly the first time regarding Although undiagnosed hypothyroidism in a maternal medications. A few weeks before the onset woman of childbearing age may have a significant of poor growth, the mother’s obstetrician prescribed impact on her future children, a reasonable screening an oral contraceptive. The mother then noticed a program to detect low free thyroxine during early reduction in her milk supply and discontinued the pregnancy may be difficult to achieve.8,11 Most oral contraceptive after a few days. Subjectively, the women do not routinely see a physician before con- mother reported that she felt her milk supply return. ceiving, so prevention of first trimester hypothyrox- I suspect that the amount of breast milk remained inemia by early detection and treatment may not be low. In that this was her first child, she may not have feasible. If screening is performed at the first prenatal accurately assessed her milk output. Formula sup- visit, typically around 8 to 10 weeks gestation, by the plementation was initiated and lactation was stimu- time an abnormal screening test is confirmed, thy- lated by giving the mother metoclopramide. Her roid replacement may be initiated beyond the period breast milk output eventually returned. The baby in fetal life at which it is required for critical brain perked right up, gained weight, and subsequently development. did well. When the oral contraceptive was prescribed, the Eustratia Hubbard, MD mother pointed out to the doctor that she was nurs- Fellow in Developmental and Behavioral Pediatrics University of California ing and specifically asked if the oral contraceptive San Diego, California would interfere with nursing. She was reassured that it would not affect nursing. When I consulted with an obstetric colleague, I learned that the brand of oral REFERENCES contraceptive prescribed was known to interfere 1. Nonacs R, Cohen L. Postpartum mood disorders: diagnosis and treat- with lactation. I learned to always ask about oral ment guidelines. J Clin Psychiatry. 1998;59(suppl 2):34–40 2. Pies RW. The diagnosis and treatment of subclinical hypothyroid states contraceptive use—patients may not think of them as in depressed patients. Gen Hosp Psychiatry. 1997;19:344–354 “medicine.” 3. Harris B, Fung H, Johns S, et al. Transient post-partum thyroid dys- Editor’s note: Oral contraceptives with estradiol are function and postnatal depression. J Affect Disord. 1989;17:243–249 more likely to be associated with breast milk reduction. 4. Harris B, Othman S, Davies JA, et al. Association between postpartum Those that include only a progesterone are less likely to thyroid dysfunction and thyroid antibodies and depression. Br Med J. 1992;305:152–156 affect lactation. 5. Pop VJ, de Rooy HA, Vader HL, et al. Postpartum thyroid dysfunction and depression in an unselected population. N Engl J Med. 1991;324: Dr Martin T. Stein 1815–1816 This case might be titled “A mother who had the 6. Thrift TA, Bernal A, Lewis AL, Neuendorff DA, Willard CC, Randel RD. wisdom to invite an attentive and informative sister Effects of induced hypothyroidism on weight gains, lactation, and reproductive performance of primiparous Brahman cows. J Anim Sci. to her home.” The pediatrician (admittedly the au- 1999;77:1844–1850 thor and not too early in his pediatric career) ob- 7. Miyake A, Tahara M, Koike K, Tanizawa O. Decrease in neonatal served the mother’s fatigue, sleep deprivation, and suckled milk volume in diabetic women. Eur J Obstet Gynecol Reprod multiple environmental stressors, but he did not no- Biol. 1989;33:49–53 8. Morreale DE, Obregon MJ, Escobar DR. Is neuropsychological development related to maternal hypothyroidism or to maternal hypothy- ‡ A bimonthly discussion of an upcoming Challenging Case takes place at roxinemia? J Clin Endocrinol Metab. 2000;85:3975–3987 the Developmental and Behavioral Pediatrics Web site. This Web site is 9. Pop VJ, Kuijpens JL, van Baar AL, et al. Low maternal free thyroxine sponsored by the Maternal and Child Health Bureau and the American concentrations during early pregnancy are associated with impaired Academy of Pediatrics section on Developmental and Behavioral Pediatrics. psychomotor development in infancy. Clin Endocrinol (Oxf). 1999;50: Henry L. Shapiro, MD, is the editor of the Web site. Martin Stein, MD, the 149–155 Challenging Case editor, incorporates comments from the Web discussion 10. Pop VJ, de Vries E, van Baar AL, et al. Maternal thyroid peroxidase into the published Challenging Case. To become part of the discussion antibodies during pregnancy: a marker of impaired child development? at the Developmental and Behavioral Pediatrics home page, go to www. J Clin Endocrinol Metab. 1995;80:3561–3566 dbpeds.org.

Downloaded from www.aappublications.org/news by guest on September 24, 2021 SUPPLEMENT 1471 tice the myxedema facial appearance. In fact, at the observed that the revised Centers for Disease Control time, maternal hypothyroidism was not considered and Prevention growth charts, generated with a among potential organic causes for failure to thrive higher proportion of breastfed infants, are a more in a nursing infant. Similar to other examples in the accurate assessment of growth in these babies. ongoing education of a physician, since this initial Both Drs Kessler and Hubbard emphasized the case, other infants with early growth failure second- multiple psychosocial risk factors that may have con- ary to maternal hypothyroidism have been seen. tributed to Christine’s poor weight gain. The physi- My sustained interest in the field of developmental ology of lactation is bound intimately to the environ- and behavioral pediatrics comes from a recognition ment of baby and mother. Christine’s pediatrician of 1 central element. Developmental-behavioral pe- was also sensitive to these factors. She wisely made diatrics focuses on the dynamic interactions between use of the initial office visit when she included a biological and psychological phenomena. We recog- direct observation of nursing as a part of the assess- nize the potential role of psychological and social ment. In addition, Dr Kessler pointed out the impor- factors in the child with an organic illness (eg, the tance of infant temperament in the assessment. Al- importance of environmental factors in the treatment though we were not given information about and outcome of children with asthma1 and attention- Christine’s temperament, he observed that “passive, deficit hyperactivity disorder2). At the same time, we undemanding infants may fuss less and consume also are attentive to possible biological contributors less than the required amount of calories needed for in the child with a behavioral or psychosomatic dis- growth in this rapid growth phase of infancy.” order (eg, the importance of considering occult con- Most clinical situations similar to this case will not stipation, lactose intolerance, giardia, or a urinary result in a diagnosis of maternal hypothyroidism. A tract infection in a school-aged child with recurrent more likely diagnosis in a similar situation might be abdominal pain—a condition most often without a maternal postpartum depression; the evidence in this clear organic cause and often associated with chal- case for that diagnosis was incomplete. It is a re- lenging events in the child’s life or family conflict3). minder, however, of the role of pediatricians to be A pediatrician’s training in biological medicine, child sensitive to a mother’s mood and physical appear- development, and behavioral pediatrics prepares ance at the time of office visits (especially in the early him or her to analyze clinical situations similar to the months after the birth of a baby). Emotional lability, current case with a comprehensive model. withdrawn behavior, and signs of sleep deprivation Dr Kessler was not aware of the interim history provide clues to depression. An empathic statement, that revealed the mother’s hypothyroid condition. similar to the one by Christine’s pediatrician, that His commentary is a fine example of a biopsychoso- “You look exhausted. It must be really tough to care cial approach to understanding the cause of Chris- for 3 young children” provides an opportunity for tine’s failure to thrive. On the biological side, he further gathering of data. During some health-super- noted the importance of a knowledge about expected vision visits, the effective therapeutic intervention daily growth in a breastfeeding infant at this age. (for mother and baby) is a timely referral of the That “slower increase in weight can be particularly mother for an evaluation and treatment of depres- prominent between 3 and 12 months [in breastfed sion. infants] and is of no concern in the otherwise healthy infant” is relatively new information from studies in REFERENCES the past decade. In addition, he emphasized the im- 1. Stein MT, Meltzer EO, Stein REK. Challenging case: recurrent episodes of portance of interpreting growth charts correctly. asthma in a 10 year old. J Dev Behav Pediatr. 1998;19:41–44 2. Stein MT, Levine M, Reiff M. Challenging case: school underachievement With the recognition that exclusively breastfed in- in the fifth grade. J Dev Behav Pediatr. 1996;17:109–113 fants can show significant decrease in weight-for-age 3. Stein MT, Rappaport L, Frazer CH, Zeltzer L. Recurrent abdominal pain. growth on the 1977 NCHS growth charts, Dr Kessler J Dev Behav Pediatr. 1995;16:277–281

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