Hyperferritinaemia following intrauterine transfusions for Rh isoimmunisation.

Intrauterine transfusion is one of the mainstays of treatment in isoimmunised pregnancies guided by the changes in middle cerebral artery Doppler of the fetus. The common postnatal complications associated with Rh isoimmunisation are high unconjugated bilirubin requiring blood exchange transfusions, cholestasis due to bile inspissation, thrombocytopenia and anaemia. Hyperferritinaemia is an uncommon adverse effect observed in Rh isoimmunised pregnancies. In this case report, we describe the clinical course of a Rh isoimmunised neonate with hyperferritinaemia and transfusion acquired cytomegalovirus disease which resolved. Iron chelation therapy was not necessary.

Growth-and Documentation-Deficits: Where To Start in Helping Families.

CASE: Pedro is a 2-year 7-month-old boy who was presented for the first time after a visit to a local emergency room (ER) for diarrhea. At the time of his birth, his undocumented mother, Clara, was 20 years old, uninsured, and with limited English proficiency living approximately 400 miles south of our practice in a different state. Although she had been brought to the United States as a child, she had never finished high school. Pedro was born what mother thought was full-term at his parent's home, where a lay midwife assisted during the delivery. Pedro was not brought to a medical facility at birth; therefore, neither medical nor legal documentation of his birth in the United States, or elsewhere, existed.After enduring 4 years of ongoing verbal and physical abuse, Clara fled to her maternal aunt in our community. The child's initial exposure to medical care was during the emergency visit, which ended up in referral to us. The ED physician suggested that the child visit a primary care physician, but establishment of pediatric care was not made until months later. The child received his first vaccines and immediately was referred to the Growth and Nutrition clinic due to mild wasting and stunting based on Waterlow criteria.Pedro speaks both English and Spanish and has no 2-word combinations and a 50-word combined vocabulary in English and Spanish. In addition, a complete blood count was consistent with iron deficiency anemia, but both sickle cell and G6PD screening are negative.The nutritionist from the specialty clinic obtained a detailed history including overall appetite, feeding skills, meal plans, and eating environment noting that the child was a competent finger feeder. The family's meals were distributed throughout the day as a meal at home and a shared fast food meal while accompanying mother, as she worked as a hair stylist 6 days per week. In addition, the diet is supplemented by ricewater mixed with sugar and ground carrots throughout the day.Where would you head next?REFERENCE1. Waterlow JC. Classification and definition of protein-calorie malnutrition. Br Med J. 1972;3:566-569.

Growth in children with congenital diaphragmatic hernia during the first year of life.

PURPOSE: Infants with congenital diaphragmatic hernia (CDH) have high rates of mortality and long-term morbidity, including poor growth and failure to thrive. The aim of this study was to describe growth patterns during the first year of life in infants with congenital diaphragmatic hernia in a non-ECMO cohort. METHODS: Medical records of infants with CDH admitted to our center between January 2005 and December 2011 were reviewed. Infants with anthropometric measurements at 3, 6 and 12months were included. Anthropometric measurements were obtained for the first year of life. Logistic regression analyses were performed to find predictive associations with failure to thrive (FTT). RESULT: Of the 45 survivors, 38 were seen twice (84%) and 24 (53%) were seen on three occasions to age 12months. Poor growth was observed with weight being most affected. FTT was present in 63% during the first six months of life. Days of mechanical ventilation were the only predictor of FTT. Besides poor weight gain, height and head circumference were also reduced. However, catch-up growth occurred during the second half of infancy and at age 12months failure to thrive had reduced by two thirds to 21%. CONCLUSIONS: Poor growth is a common early finding in CDH patients, which improves during infancy. This emphasizes the importance of close follow-up and aggressive nutritional management in CDH patients.

Growth--and documentation-deficits: where to start in helping families.

REFERENCE: Pedro is a 2-year 7-month-old boy who was presented for the first time after a visit to a local emergency room (ER) for diarrhea. At the time of his birth, his undocumented mother, Clara, was 20 years old, uninsured, and with limited English proficiency living approximately 400 miles south of our practice in a different state. Although she had been brought to the United States as a child, she had never finished high school. Pedro was born what mother thought was full-term at his parent's home, where a lay midwife assisted during the delivery. Pedro was not brought to a medical facility at birth; therefore, neither medical nor legal documentation of his birth in the United States, or elsewhere, existed.After enduring 4 years of ongoing verbal and physical abuse, Clara fled to her maternal aunt in our community. The child's initial exposure to medical care was during the emergency visit, which ended up in referral to us. The ED physician suggested that the child visit a primary care physician, but establishment of pediatric care was not made until months later. The child received his first vaccines and immediately was referred to the Growth and Nutrition clinic due to mild wasting and stunting based on Waterlow criteria.Pedro speaks both English and Spanish and has no 2-word combinations and a 50-word combined vocabulary in English and Spanish. In addition, a complete blood count was consistent with iron deficiency anemia, but both sickle cell and G6PD screening are negative.The nutritionist from the specialty clinic obtained a detailed history including overall appetite, feeding skills, meal plans, and eating environment noting that the child was a competent finger feeder. The family's meals were distributed throughout the day as a meal at home and a shared fast food meal while accompanying mother, as she worked as a hair stylist 6 days per week. In addition, the diet is supplemented by rice water mixed with sugar and ground carrots throughout the day.Where would you head next?

[Eat a citrus fruit, stay healthy--a case report of scurvy].

Scurvy is a disease that results from a vitamin C deficient diet. Since vitamin C is available in many food products, and especially in citrus fruits, the disease is rare in developed countries. Clinical manifestations of scurvy include general weakness, cutaneous and gum bleeding, pain in the lower limbs and inability to stand and walk (pseudo paralysis). The diagnosis of scurvy requires a high level of clinical suspicion, typical radiographic features and low Levels of vitamin C in the plasma. We report a case of a 7-year-old patient with a medical history of hydrocephalus, failure to thrive and severe psychomotor retardation due to complications of prematurity. On admission she had gum bleeding, severe anemia, pain in the lower limbs and refused to stand and walk. According to her parents, her diet was restricted, without vegetables or fruit consumption. Our investigation ruled out coagulopathy, malignancy and infection. Serum vitamin C levels were low and radiographic findings were consistent with the diagnosis of scurvy. The patient improved rapidly after the initiation of vitamin C supplements. Despite being rare, scurvy should be considered in the differential diagnosis of bleeding and pain in the lower limbs, especially in a malnourished patient.

Failure to thrive in childhood.

BACKGROUND: Failure to thrive impairs children's weight gain and growth, their defenses against infection, and their psychomotor and intellectual development. METHODS: This paper is a review of pertinent articles that were published from 1995 to October 2010 and contained the terms "failure to thrive", "underweight", "malnutrition", "malabsorption", "maldigestion" and "refeeding syndrome". The articles were retrieved by a search in the PubMed and Cochrane Library databases. RESULTS: In developed countries, failure to thrive is usually due to an underlying disease. The degree of malnutrition is assessed with anthropometric techniques. For each patient, the underlying disease must be identified and the mechanism of failure to thrive understood, so that proper medical and nutritional treatment can be provided. Nutritional treatment involves either giving more food, or else raising the caloric density of the patient's food. Liquid formulas can be given as a supplement to normal meals or as balanced or unbalanced tube feeds; they can be given orally, through a nasogastric tube, or through a gastrostomy tube. Severely malnourished children with poor oral intake should be treated with parenteral nutrition. To avoid refeeding syndrome in severely malnourished children, food intake should be increased slowly at first, and phosphate, magnesium, and potassium supplements should be given. CONCLUSION: The proper treatment of failure to thrive in childhood consists of treatment of the underlying illness, combined with nutritional treatment that addresses the mechanism of the accompanying failure to thrive.

The adolescent child with short bowel syndrome: new onset of failure to thrive and need for increased nutritional supplementation.

BACKGROUND: Proper nutrition for children with short bowel syndrome (SBS) is challenging. An underappreciated SBS cohort is the group of adolescents in which nutritional demand is markedly increased. We identified several children that previously had weaned off parenteral nutrition but needed re-initiation of parenteral nutrition or increased enteral nutritional supplementation (NS) during adolescence. This study aims to identify characteristics of adolescent SBS patients to better understand their nutritional status. METHODS: A single institution, retrospective review of SBS patients over 10 years was done. Patients were analyzed for NS need, remaining bowel length, height, weight, and essential nutrient levels. RESULTS: Sixteen adolescent SBS patients were identified for analysis. Of these, ten did not require increased NS upon reaching adolescence (group A), and six required increased NS during adolescence (group B). Group B patients required a mean increase in NS of 29.6 kcal/kg per day. Group B patients had significantly shorter remaining bowel length. NS resulted in minimal height increase, but more substantial gains in weight and pubertal development. CONCLUSIONS: Adolescents with SBS may require NS beyond what can be provided enterally. These patients are at risk for nutritional deficiencies, and an aggressive approach to monitoring and supplementing these deficiencies is warranted, especially during this critical period of growth.

Bovine colostrum in the management of nonorganic failure to thrive: a randomized clinical trial.

OBJECTIVE: The objective of the study was to evaluate the clinical efficacy of oral bovine colostrum in the management of nonorganic failure to thrive (FTT). MATERIALS AND METHODS: In a randomized clinical trial, 120 children (1-10 years of age) of either sex with mild or moderate nonorganic FTT were divided into 2 groups. Both groups were matched with regard to age, sex, weight, and height. One group (control) received routine treatments for FTT and the other group (case), besides routine treatments, received supplementary bovine colostrum at the dose of 40 mg . kg . day for a 3-month period. Following the initial visit, subsequent visits were completed following 1, 2, and 3 months of supplementation. For quantitative measurements, Waterlow I (height for age) and Gomez (weight for age) indices were used. RESULTS: The mean value of Gomez index in the case group (81.72) was significantly higher than the control group (77.12) at the end of the third month of supplementation (P = 0.003). Such a difference was not reported based on Waterlow I index between the case and control groups (92.91 vs 91.71; P = 0.094). According to Gomez index 12 patients (20%) who received colostrum became healthy at the end of the third month, which was significantly higher than the control group (2 cases, 3.3%); P = 0.006. CONCLUSIONS: Bovine colostrum supplementation for a 3-month period is a useful method without any side effects, in addition to known medical and psychological treatments, to increase the weight of children with nonorganic FTT.

[Consequences of exclusive breast-feeding in vegan mother newborn--case report]. / Conséquences de l'allaitement maternel exclusif chez le nouveau-né de mère végétalienne--A propos d'un cas.

We report on the case of an infant who was hospitalized because of failure to thrive, megaloblastic anemia, and delayed psychomotor development. He was 10 months old and had been exclusively breast-fed by his vegan mother. Investigations showed vitamin B(12) deficiency with hematocytopenia and pervasive developmental disorders as well as vitamin K and vitamin D deficiencies. The infant's mother presented the same deficiencies. Introduction of vitamin supplementation normalized the biological disorders, and the infant showed weight gain and neurological improvement. This case highlights that a vegan diet during pregnancy followed by exclusive breast-feeding can induce nutritional deficiencies in the newborn, with clinical consequences. Detecting mother and child vitamin deficiencies and preventing them is essential.

Dysphagia and nutrition problems in infants with apert syndrome.

OBJECTIVE: The purpose of this study was to identify and describe the nature of dysphagia and nutrition difficulties in infants with Apert syndrome. DESIGN: The study comprised a review of the medical, nutrition, and feeding records of 13 consecutive infants still feeding by the bottle who had been referred to the Craniofacial Unit and analyses of swallow function from videofluoroscopic swallow investigations. MAIN OUTCOME MEASURES: Outcome measures included qualitative analyses of bottle-feeding and nutritional status and quantitative functional severity ratings of dysphagia based on videofluoroscopic swallow investigations using the O'Neil et al. (1999) Dysphagia Outcome Severity Scale. RESULTS: The main qualitative descriptors of oral feeding in this cohort included uncoordinated suck-swallow-breathe patterns, inability to maintain sucking bursts, and changes in respiratory patterns as the feed progressed. Videofluoroscopic evaluations (N = 7) showed silent laryngeal penetration or aspiration in more than half of the cohort. Failure to thrive was a frequent occurrence seen in seven infants, and 9 of the 10 required dietetic intervention and enteral supplements. (Nutritional records were not located for three infants.) CONCLUSIONS: In view of the small sample size and retrospective nature of the study, the results need to be interpreted with caution. However, the study adds to current limited knowledge on feeding and nutrition in Apert syndrome. Further prospective multidisciplinary and objective research is clearly warranted.

Effects of formula supplementation in breast-fed infants with failure to thrive.

BACKGROUND: The aim of the present study was to assess whether formula supplementation of infants with failure to thrive can improve underweight without jeopardizing breast-feeding. METHODS: In a prospective intervention study 31 term exclusively breast-fed infants were studied, who were admitted to hospital at an age of 28-99 days with failure to thrive (< or =40% expected weight gain for age and/or bodyweight < or =10th percentile for age) without underlying disease. Infant formula was offered ad libitum after each breast-feeding, while continued breast-feeding was supported. RESULTS: Energy intake per day increased from 352 +/- 111 kJ/kg (mean +/- SD) at study start to 587 +/- 115 kJ/kg (P < 0.001, days 1-3 of supplementation) and 501 +/- 99 kJ/kg (days 29-31; P < 0.001 vs study entry). Twenty-five infants continued to be partially (n = 21) or fully (n = 4) breast-fed. Human milk intake decreased from 476 +/- 163 g/day (study days 1-3) to 349 +/- 285 g/day (study days 29-31; P < 0.01). The contribution of breast milk to total milk intake decreased from 100% to 42 +/- 35% (P < 0.001). Supplementation over 31 days led to increased weight (0.98 [0.70], standard deviation scores [SDS]), length (+0.40 [0.41] SDS) and head circumference (+0.59 [0.93] SDS). CONCLUSIONS: One month of formula supplementation successfully improved growth in 72% of infants with failure to thrive on human milk feeding. Breast-feeding was maintained in 81% of infants.

A clinical study of the intergenerational transmission of eating disorders from mothers to daughters.

Clinicians and researchers have long recognized the existence of eating disorders in very young children, including infants whose mothers have eating disorders. This paper combines reviews of the literature relevant to the study of eating disorders from the perspectives of both research and psychoanalytic theory in order to explore the psychodynamics of the intergenerational transmission of eating-disordered pathology from mother to child. A developmental pathway as well as several mechanisms that illuminate the pathogenesis of the intergenerational transmission of eating disorders are proposed and described. Clinical-observational data from a therapeutic play nursery for mothers with eating disorders and their children are presented, and this material is examined in relation to the proposed psychodynamic pathways of transmission.

Iatrogenic malnutrition in neonatal intensive care units: urgent need to modify practice.

BACKGROUND: Extrauterine growth retardation is a major clinical problem in very-low-birth-weight infants. Parenteral nutrition (PN) serves to achieve rapid maximal nutrition in early postnatal life. There is a lack of uniformity with regard to neonatal PN practice. The objective of this study is to ascertain current practice regarding neonatal PN prescription in the early postnatal period in the United Kingdom. METHODS: A study questionnaire was e-mailed to neonatal pharmacists serving level 3 and major level 2 units in the United Kingdom between October 2005 and March 2006. Static numerical information regarding glucose, amino acids, and lipid prescription during the first 10 days of life was collected and compared with current recommendations. RESULTS: Fifty-two (81%) units responded to the questionnaire; 4 units were excluded for incomplete data. Twenty-six units (54%) initiated PN on day 1. Full PN was achieved by the median age of 6 days. Twelve units (25%) achieved full PN only by day 7 or later. Maximum median amino acids were 2.9 g/kg/d. Only 13 units (27%) prescribed >/=3 g/kg/d, and 2 prescribed more than 3.5 g/kg/d. Nineteen units (39%) initiated lipids on day 1. Eleven units (23%) delayed lipids until day 3, and 2 units delayed lipids until day 4. In comparison to the recommended intake of calories and amino acids, the current median prescription would result in a cumulative deficit over the first 10 days of 420 kcal/kg and 11.9 g/kg, respectively. CONCLUSIONS: Our study suggests diverse practice with regard to neonatal PN prescription in the United Kingdom. Current neonatal PN practice entails a significant calorie and protein deficit during early postnatal life and warrants further review.

Disease severity at time of referral for pediatric failure to thrive and obesity: time for a paradigm shift?

The percent of ideal body weight at first visit to pediatric referral clinics was compared by chart review between patients with failure to thrive and obese patients. Results indicated that underweight children were mildly underweight, whereas the overweight children were severely so. In primary care settings, underweight children may be referred more aggressively than overweight children.

Clinical health problem: failure to thrive.

Families in which NOFTT is present need interventions that target behaviors and identify stressors that contribute to decreased caloric intake. A holistic approach to the situation is required, to deal with considering the problem which may stem from multiple sources. Maternal perceptions of health and diet can be influenced by the practitioner in a sensitive manner, encouraging balance. Infant feeding difficulties can be identified by the practitioner and appropriate referrals can be made to FTT clinics that are experienced in working with these infants and their caregivers. Public health nurses can be utilized to further assess families, follow up on health teaching, and provide referrals to community resources to alleviate stressors. Management of NOFTT by a practitioner in the primary care setting is feasible and cost-effective.

A prospective study of family environments of children hospitalized for nonorganic failure-to-thrive.

Family functioning of nonorganic failure-to-thrive (NOFT) infants was compared with that of physically healthy, normally growing infants of similar socioeconomic status shortly after the time of the diagnosis of this condition (average age of 5 months) and again at 4 years of age. Families of NOFT infants demonstrated less adaptive relationships than did comparison-group infants, as measured by the Family Relationships Inventory (FRI) at both time points, but a comparable number of changes in residence and constellation on follow-up. Contrary to prediction, the quality of family relationships at point of diagnosis did not predict subsequent family relationships, residence, or constellation changes in the NOFT sample. However, more adaptive family relationships in the comparison group at study entry predicted fewer residence and constellation changes and more cohesive relationships 3 years later. The impact of significant discontinuities in family functioning and status should be considered in research and in clinical interventions with NOFT children.