An unexpected cause of infantile failure to thrive.

The etiology of infantile failure to thrive in the US is extremely diverse. Causes range from naive or malevolent parents; cost of formula for low-income families; mothers inexperienced with breast-feeding; and a range of organic causes. Many experts categorize failure-tothrive (FTT) as either organic or nonorganic. Recognizing the initial stages of FTT is challenging, but becomes readily apparent over weeks of infant office visits by observing basic vital signs and growth curves. However, many insurance companies and Medicaid EPSDT only allow these in the first week of life and then again at 2 months of age. I am afraid this means we are going to miss some serious cases of FTT (and newborn jaundice). We should probably ensure the healthy newborn who is breastor bottle-fed is gaining weight steadily by incorporating a second office visit or a nurse visit at 10 to 14 days of life — regardless of insurance coverage or how payments are capped. CASE 1 The 2-month-old, healthy female had a birth weight of 6 lb,10 oz as a twin gestation. Her antenatal course, labor and delivery, and newborn hospital course were uncomplicated. She had been feeding 2 to 3 oz of standard milkbased formula every 2 to 3 hours with a weight gain of 16 oz over the previous 21 days. At this visit, her physical examination was entirely normal. At 3 months old, the patient presented with a chief complaint of constipation noted by small, hard round stools. The mother reported the child was bottle feeding about 4 oz every 3 hours, plus the mother reported adding some rice cereal to most of her bottles. But the child had gained only 8 oz in 1 month. The patient’s head circumference and length were on the appropriate growth curves, and her vital signs and overall examination were normal except for her mild malnourished appearance and loss of subcutaneous body fat. The infant also was very cranky, even while feeding. I decided to evaluate her apparent FTT more thoroughly. The initial laboratory evaluation revealed that her CBC was normal except for her leukocyte count, which was elevated at 17,500 cells/mm3. This prompted me to perform even more tests to exclude a possible infectious source of her FTT. She had a normal urinalysis with a specific gravity (SG) of 1.010 and no ketones. Her urine culture by catheterization was negative. Her chest radiograph was negative. Her An Unexpected Cause of Infantile Failure to Thrive