Case discussion: FTT in first month of life

[oldbearprofessor]

George (randomly picked name, not related to the guy who was a British tyrannical monarch) is a 21 day old infant who is admitted to the wards for failure to thrive (FTT).

Birth history: Born at 39 3/7 weeks vaginal delivery, Apgars 8/9. Birth weight 3.8 kg, no length or head circumference reported. Second baby. First child is 2 yrs old and healthy and did not have this problem.

Admission information: Current 3.5 kg, length is 10%ile using WHO curves and FOC has not been measured.

Diet and medical history: mom initially breast-fed the infant but he seemed to take it poorly so at 10 days of age she began giving some formula supplement. Initially she used a routine formula but after talking to her pediatrician, she switched to a low lactose formula (cow milk protein).

Okay gang:

Differential and thought processes?
Initial testing?
Further history?

Based on multiple cases, but not any one infant.

---

Members don't see this ad.

 

[PTPoeny]

I will bite.

Differential DX: (no particular order)
Inborn error of metabolism
Hypermetabolic state- CF, CHD
Malabsorption - CF, GI issue
Genetic syndrome - a trisomy, achondroplasia
Infection - TORCH or post birth infection
Hypothyroid
RTA
Organic feeding difficulty-laryngomalacia, severe ankyloglossia, TEF,
Psychosocial
Inappropriate feeding practices
Emotional neglect

Thought process: (sorry, it will be brief, on a tablet, not a real computer)
Some if these things would be able to be ruled out by looking at the baby. Basically either the baby isn't getting enough calories, can't use the calories or needs an excessive number of calories.

Further history I would like to get:

State newborn screen results
Do we have any weight, length and hc measurements over the last 21 days from the pediatrician's office?
Are the parents mixing formula? How often are they feeding? What have they tried?
What does the baby look like while they tried to feed?
What problems was the baby having with breastfeeding?
One thing that isn't clear, is the mother still breastfeeding and just supplementing? Or did she transition totally to low lactose formula?
Is the baby eliminating normally?

I would like to watch the parents mix a bottle and feed the baby in addition to a normal PE.

For tests I would want a CBC, bmp, tsh, repeat state newborn screen if not already done. I'm guessing that's about as much blood we can draw for one day?

 

[oldbearprofessor]

Anyone else?

I'll add more and comment later in the next day or two. I would note that it is difficult usually to get the family to bring in their formula and show you how they mix it, although that's a good idea.

What do you think about using a low lactose formula for feeding problems in the first month of life? What is the rationale for that and is it a good one?

 

[PTPoeny]

What do you think about using a low lactose formula for feeding problems in the first month of life? What is the rationale for that and is it a good one?

It's a little unclear why it was started. A low lactose formula is needed if there is a concern for galactosemia or something similar. But usually it seems to be something parents try when a baby is fussy or gassy or a happy spitter or has colic. I guess an important question would be to try and figure out if their doctor was concerned about a milk protein allergy and there was some confusion about what to change in the formula.

I think it is unlikely to help, unlikely to hurt in general. It's really silly to use as a supplement to breastfeeding,

 

[J-Rad]

I'd like the story of how the baby is eating i.e. patterns, associated observations of the parents. Next would be physical exam.

 

[BigRedBeta]

History, history, history, history!

As others have said, want to know lots about feeding:what, when, how, frequency, amounts, spitting up, tachypnea, diaphoresis, and what were the issues with breast feeding. Would also want to know about true lethargy, not waking to feed, cyanosis, # of wet diapers.

A thorough physical exam including facial features to rule out syndromic facies, murmurs, abnormal movements and the like. Depending on the physical exam, I might add in liver function tests, ammonia, VBG or Cap Gas, and a lactate.

 

[oldbearprofessor]

In thinking about infants with FTT in the first weeks of life, the focus should be on a failure of the intake side. It is possible to have malabsorption or metabolic disorders, but unless there is a real likelihood of CF or a sick looking baby, these are uncommon as is FTT as a presentation of congenital heart disease in a small child (but not impossible....usually there are other clues to that).

In terms of output, lacking a story for diarrhea, this is also unlikely as a reason for FTT.

So, focusing on the intake, it can be extremely challenging to figure out what is going on. These infants often have a history of some breastfeeding, multiple formulas being tried, some emesis and sometimes parents who are not great at telling any type of story. For this purpose, lets assume the best one can get is a vague history of some breastfeeding, some formula and some emesis. Really it is tough to pin folks down, although it's worth a try.

Lets also assume that the dietitian has spoken to mom on the phone and will meet with her in the next couple of days (it is a Friday night admit...) to review formula use, mixing, etc.

Ultimately, from a diagnostic process, after getting a basic metabolic profile (lytes and glucose), some liver and kidney function testing and perhaps a CBC and lactate, one has to decide whether radiographic studies are needed and what to try to feed the baby.

What in the history or PE would make one get an u/s of the pylorus and/or an UGI? How would you evaluate the possibility of milk protein allergy?

What formula would you try? Is there a reason not to allow to breast-feed? If so, how would you assess volume of intake.

Note that this is not CME so you can use actual formula names if you'd like.....

 

[PTPoeny]

The baby is a bit younger than the textbook presentation of pyloric stenosis, but if the parents are talking about projectile vomiting and describing it going several feet and hitting the wall I would get the US. Also with that I would be more concerned if we got a history that the baby grew well initially and then stated losing weight recently. The parents will also frequently say the baby seems hungry right away after vomiting.

I would be considering an UGI if the history makes it sounds like the baby is having trouble getting food down- the baby seems hungry, wants the bottle but doesn't actually take much during a feed. I would also want to get imaging faster if the baby looked dysmorphic.

If mom is still breastfeeding I would have her continue and weigh the baby before and after each feed on the same scale and in a diaper in this case. If mom isn't breastfeeding I would do a hemeoccult on a diaper and start the baby on mom's choice of normal formula if it is negative and on something like nutramigen if positive. Either way I would want the baby offered a chance to feed every 2 hours. If the baby is bottle fed I would talk to the night nurse and ask her to offer to feed the baby at least once overnight and keep track of which feeds were done by the nurse.

 

[oldbearprofessor]

If mom is still breastfeeding I would have her continue and weigh the baby before and after each feed on the same scale and in a diaper in this case. If mom isn't breastfeeding I would do a hemeoccult on a diaper and start the baby on mom's choice of normal formula if it is negative and on something like nutramigen if positive. Either way I would want the baby offered a chance to feed every 2 hours. If the baby is bottle fed I would talk to the night nurse and ask her to offer to feed the baby at least once overnight and keep track of which feeds were done by the nurse.

You definitely have the right idea here. The problem is most likely on the intake side, not a rare malabsorptive syndrome. Most commonly it is simply a baby that is a poor feeder, often from initial breastfeeding not going well and not having good lactation support. Sometimes it is a late preterm who never quite gets the hang of it. One should be cautious about making the diagnosis of cow milk protein (CMP) intolerance and switching to a casein hydrolysate formula. They are much more expensive and most babies who are FTT are not CMP intolerant. A guaiac positive stool is not all that compelling.

How much formula would you write as the minimum over 24 hours for a 3 week old infant? What about a two month old infant? What would be the maximum you'd allow? Why?

 

[J-Rad]

CNN usually sucks for the quality of its medical newsreporting, hwoever, on occasion, something compelling comes up and I find it worthwhile to peruse their medical reporting. I thought this recent article touching on medical reasons for breast feeding failure was interesting: http://www.cnn.com/2013/01/03/health/medical-breastfeeding.

 

[PTPoeny]

How much formula would you write as the minimum over 24 hours for a 3 week old infant? What about a two month old infant? What would be the maximum you'd allow? Why?

My formula goals would depend on the baby's weight and if they look like they need some catch up, or just to start growing better. For a baby that needs catch up I would write for 120 kcals/kg/day. For a baby that just needed to start growing better i would do 100-110 kcals/kg per day. Assuming breastmilk or standard formula that is ~5 ounces per kg.

I would adjust the amount downwards if over two days, weighed naked, at the same time of day on the same scale the baby was growing more than 35g/day for a baby I wanted catch up growth or 20-25g/day for a baby that doesn't need catch up growth.

Interesting article.