A 6-month-old girl is brought to the office for the first time for a well-child visit. The family recently relocated to the area to be close to a sick family member. Review of medical records shows an uncomplicated labor and delivery at 38 weeks gestation. Birth weight was 3.4 kg (7 lb 8 oz), which was at the 50th percentile. Head circumference and length were documented at the 60th percentile. At the 2-month visit before the family's relocation, she received her 2-month vaccinations and was documented at the 45th percentile for weight. She was not seen for a 4-month visit. The patient is able to sit with support and roll over. She is babbling consonants and reaching for toys. She drinks approximately 30 ounces of formula a day. Her parents started her on solids at age 5 months, and she eats fruits and vegetables twice a day. The patient lives at home with her parents and 2 older brothers. Weight today is 6.2 kg (13 lb 11 oz), which is at the 8th percentile; head circumference and length are at the 60th percentile. Physical examination shows an alert and active infant. She transfers a toy from her right to left hand. The remainder of the physical examination is unremarkable. The parents seem frustrated as the girl's 2-year-old brother takes the girl's toy and she screams. What is the most appropriate next step in management of this patient?

Question

A 6-month-old girl is brought to the office for the first time for a well-child visit.  The family recently relocated to the area to be close to a sick family member.  Review of medical records shows an uncomplicated labor and delivery at 38 weeks gestation.  Birth weight was 3.4 kg (7 lb 8 oz), which was at the 50th percentile.  Head circumference and length were documented at the 60th percentile.  At the 2-month visit before the family's relocation, she received her 2-month vaccinations and was documented at the 45th percentile for weight.  She was not seen for a 4-month visit.  The patient is able to sit with support and roll over.  She is babbling consonants and reaching for toys.  She drinks approximately 30 ounces of formula a day.  Her parents started her on solids at age 5 months, and she eats fruits and vegetables twice a day.  The patient lives at home with her parents and 2 older brothers.  Weight today is 6.2 kg (13 lb 11 oz), which is at the 8th percentile; head circumference and length are at the 60th percentile.  Physical examination shows an alert and active infant.  She transfers a toy from her right to left hand.  The remainder of the physical examination is unremarkable.  The parents seem frustrated as the girl's 2-year-old brother takes the girl's toy and she screams.  What is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Failure to thrive (FTT) is defined by weight below the 5th percentile or down-trending weight percentiles crossing 2 or more major percentiles (eg, 50th, 25th, 10th). Causes of FTT include inadequate calorie intake, inadequate calorie absorption (eg, cystic fibrosis, celiac disease), and increased calorie requirements (eg, hyperthyroidism, congenital heart disease). The most common etiology of FTT is inadequate calorie intake secondary to psychosocial stressors. These include poverty (eg, lack of access to food), lack of knowledge of appropriate feeding techniques (eg, excessive water-to-formula powder ratio), and poor parental/child relationship (eg, neglect, abuse). The first step in any case of FTT is to perform a thorough history and physical examination to discover clues as to the cause. In this patient, a detailed diet history, including formula preparation and solid food intake, is the next appropriate step. (Choice A) Although catch-up vaccinations are indicated, causes for FTT must be investigated and close follow-up is required to ensure catch-up growth. (Choices B and E) Celiac disease can present with FTT in infancy; however, abdominal pain and chronic diarrhea would likely be present. If caloric intake is determined to be appropriate for age, screening for celiac disease can be considered. In addition, other reasonable tests include complete blood count and comprehensive metabolic panel to evaluate for anemia/malignancy or renal disease, respectively. (Choice D) Involvement of Child Protective Services without first exploring causes for FTT with the family is inappropriate. This family has several potential psychosocial stressors that should be explored (eg, family illness, recent move, multiple children). Educational objective: Failure to thrive is most commonly due to psychosocial stressors. Investigation always begins with a detailed diet history to evaluate for inadequate or inappropriate nutrient intake. References: Failure to thrive. (http://www.ncbi.nlm.nih.gov/pubmed/23604606)

A 6-Month-Old Girl Is Brought to the Office for the First