BENDING THE VALUE CURVE Probability, Uncertainty, and Value in Inpatient Diagnosis: Connecting the Dots

A 1-year-old child who emigrated from Africa at 8 months of age was admitted for evaluation of failure to thrive (FTT) and hypotonia. Her birth weight was 3.35 kg (46th percentile), and on hospital admission, she weighed 6.2 kg (0 percentile). Her mother had full prenatal care in Africa and was HIV negative in her third trimester. The child was exclusively breast fed until 6 months when she was converted to formula and various foods customary to her culture. In addition to 4 bottles of formula per day of varying volumes, the mother offered pureed baby food such as vegetables and fruits, but her daughter refused. Two months before admission, she was referred to an outpatient neurologist for hypotonia, who recommended a brain magnetic resonance imaging scan if increased caloric intake did not improve weight gain and decrease hypotonia, but the family was lost to follow-up. On examination, she had preserved head circumference with short limbs and a prominent forehead. She sat unassisted and crawled but did not cruise or walk. Her appendicular tone was low, but the remainder of her physical examination, including axial tone, was normal.