A failure of expected growth and wellbeing – a shift in percentiles
Approach: Input vs Output
Input
- Nutrition
- Babies need 100 – 120 kCal/kg/day
- Weight gain should be ~1oz/day except Sundays
- Birth weight should be regained by 7-10 days
- Birth weight should double by 5 months, triple by 1 year and quadruple by 2 years
- Breast milk = formula = cow’s milk = 67 kCal/100cc or 20kCal/oz
- Problems
- Feeding
- Swallowing dysfunction, aspiration
- Formula mixed incorrectly
Output
- Too much out
- Reflux is normal, but babies may increase too much or be vomiting
- Diarrhea
- Insensible losses
- Increased metabolic demands
- Congenital
- Malignancy
- Recurrent infection
- Hyperthyroidism
History
- Birth history
- Feeding/Nutrition
- Stooling and voiding
- Growth pattern
- Recurrent Infections
- Hospitalizations
- HIV risk factors
- Developmental history
- Social and family history
- Review of systems
Physical exam
- Weight, height, head circumference
- Fat stores (buttocks, thighs, neck)
- Dysmorphic features
- Neurologic signs (tone)
- Developmental
- CVS/Resp/Abdo
- Signs of neglect (flat head, poor hygiene, bruises/abrasions)
Investigations
- CBCD (anemia)
- U/A (RTA)
- Lytes, urea, Cr, albumin (renal), prealbumin (assess protein stores)
- HIV, TB – if indicated
- Swallowing study (can do at bedside first to assess clinically)
- Sweat chloride (Cystic Fibrosis)
- CXR (pulmonary)
- Echo (cardiac)
* Note: wheeze and FTT think chronic lung disease (asthma, CF), if amenorrhea and weight loss think anorexia (malabsorb by drinking vinegar; hypokalemia)