Correspondence
3. ALLHAT Officers and Coordinators for the ALLHAT Col-
laborative Research Group. Major outcomes in high-risk hyper-
tensive patients randomized to angiotensin-converting enzyme
inhibitor or calcium channel blocker vs diuretic: the Antihyper-
tensive and Lipid-Lowering Treatment to Prevent Heart Attack
Trial (ALLHAT). JAMA 2002;​288:​2981-97.
Case 31-2017: A 19-Month-Old Girl with Failure to Thrive
To the Editor: In the Case Record involving an
emaciated 19-month-old girl with a ravenous ap-
petite in whom the diencephalic syndrome was
diagnosed, Curran et al. (Oct. 12 issue)1 do not
discuss why a neuro-ophthalmological evalua-
tion to rule out intracranial hypertension was not
performed. The marked findings on imaging,
which showed compromise of the optic chiasm,
obstruction of the right foramen of Monro, and
hydrocephalus, strongly suggest that the child’s
vision might have been affected and that nystag-
mus, papilledema, and neurodevelopmental de-
lay might have been present. These signs and
symptoms compel such clinical evaluations and
were de rigueur before computed tomography
and magnetic resonance imaging became avail-
able. This case underscores the worrisome trend
in which technology is displacing simple clinical
maneuvers that in this instance might have been
more informative than many of the complex and
expensive tests that were performed.
The underlying mechanisms by which this
syndrome, in the presence of a high caloric in-
take, results in failure to thrive without im-
pinging on linear growth are unknown. Such
unexpected outcomes place current paradigms re-
garding energy balance into question. A better
understanding of this rare syndrome may provide
insights into more common conditions in which
caloric intake is affected.
Saul Malozowski, M.D., Ph.D.
National Institute of Diabetes and Digestive and Kidney Diseases
Bethesda, MD
sm007@​­nih​.­gov
The views expressed in this letter are those of the author and
do not represent an official position of the Department of
Health and Human Services.
No potential conflict of interest relevant to this letter was re-
ported.
1. Case Records of the Massachusetts General Hospital (Case
31-2017). N Engl J Med 2017;​377:​1468-77.
DOI: 10.1056/NEJMc1714806
n engl j med 378;7 nejm.org  February 15, 2018
The New England Journal of Medicine
Downloaded from nejm.org on February 14, 2018. For personal use only. No other uses without permission.
Copyright © 2018 Massachusetts Medical Society. All rights reserved.
4. Gandhi S, Mosleh W, Myers RB. Hypertonic saline with
furosemide for the treatment of acute congestive heart failure:
a systematic review and meta-analysis. Int J Cardiol 2014;​173:​
139-45.
DOI: 10.1056/NEJMc1716477
To the Editor: Curran et al. describe “a 19-month-
old girl with failure to thrive.” Replacing the
term “failure to thrive” with precise descriptive
terminology, as defined in guidelines from the
World Health Organization (WHO)1 and others,2,3
would help to facilitate the understanding of the
prevalence, prognosis, and outcomes of malnu-
trition-associated conditions. Varying definitions
of the imprecise historical term “failure to thrive”
render comparisons across studies difficult, since
as the case discussants note, there is “no univer-
sally agreed-on definition” for this term. This
child’s growth data supported a diagnosis of
moderate acute malnutrition, which the WHO
defines as a weight-for-height value of more than
2 SD below the median.1
Failing to appropriately define this child’s
nutritional status may have led to the strikingly
large number of investigations that were con-
ducted. Data that were published nearly 40 years
ago indicate that laboratory investigations rarely
identify a diagnosis that is not already suspected
on the basis of the medical history and physical
examination.4 In this rare but classic presenta-
tion of the diencephalic syndrome, an etiologic
approach to defining malnutrition and the use
of established terms to quantify it might have
reduced the delay in diagnosis and the number
of investigations.
Susanna Y. Huh, M.D., M.P.H.
Christopher P. Duggan, M.D., M.P.H.
Boston Children’s Hospital
Boston, MA
susanna​.­huh@​­childrens​.­harvard​.­edu
No potential conflict of interest relevant to this letter was re-
ported.
1. WHO child growth standards and the identification of se-
vere acute malnutrition in infants and children:​a joint statement
by the World Health Organization and the United Nations Chil-
dren’s Fund. Geneva:​World Health Organization, UNICEF,
2009.
2. Cederholm T, Barazzoni R, Austin P, et al. ESPEN guidelines
on definitions and terminology of clinical nutrition. Clin Nutr
2017;​36:​49-64.
685
 correction
3. Mehta NM, Corkins MR, Lyman B, et al. Defining pediatric
malnutrition: a paradigm shift toward etiology-related defini-
tions. JPEN J Parenter Enteral Nutr 2013;​37:​460-81.
4. Sills RH. Failure to thrive: the role of clinical and laboratory
evaluation. Am J Dis Child 1978;​132:​967-9.
DOI: 10.1056/NEJMc1714806
The discussants and a colleague reply: We
agree with Malozowski about the importance of
a detailed history and physical examination be-
fore pursuing more invasive and risky investiga-
tions for any pediatric patient, and especially for
a child with failure to thrive. Although the find-
ings of the physical examination were not ex-
plicitly described in the Case Record because of
space limitations, the findings that were noted
on admission included the absence of nystag-
mus, visual-field deficits, and developmental de-
lays. In addition, the patient lacked other signs
of increased intracranial pressure, such as over-
night awakening or vomiting, or increased dis-
comfort in a recumbent position. Her evaluation
included careful assessment by the pediatric neu-
rology service.
Since a full ophthalmologic evaluation with
dilated fundoscopic examination would have re-
quired sedation in this 19-month-old patient,
such an examination was not urgently pursued,
given the reassuring findings noted above. Rather,
as discussed in the Case Record, we continued
to rule out other causes of failure to thrive and
then arranged brain magnetic resonance imag-
ing as the next step in our workup.
As noted by Huh and Duggan, certainly the
ability to quantify malnutrition is an important
topic and will be beneficial for studies going
forward. However, in this case, the number of
investigations that were ordered had to do with
the rarity of the diagnosis. There was never any
doubt that the child was malnourished or “failing
to thrive.”
Vandana L. Madhavan, M.D., M.P.H.
Marjorie A. Curran, M.D.
Massachusetts General Hospital
Boston, MA
curran​.­marjorie@​­mgh​.­harvard​.­edu
Kristen Lindgren, M.D., Ph.D.
Newton–Wellesley Hospital
Newton, MA
686 n engl j med 378;7 nejm.org  February 15, 2018
The New England Journal of Medicine
Downloaded from nejm.org on February 14, 2018. For personal use only. No other uses without permission.
Copyright © 2018 Massachusetts Medical Society. All rights reserved.
Dr. Lindgren reports no potential conflict of interest. Since
publication of their article, Drs. Madhavan and Curran report no
further potential conflict of interest.
DOI: 10.1056/NEJMc1714806
Correspondence Copyright © 2018 Massachusetts Medical Society.
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correction
Trial of Short-Course Antimicrobial Therapy for Intraabdominal
Infection (N Engl J Med 2015;372:1996-2005). The list of authors
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footnote should have noted the presence of a list of investigators
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