S

"Not gaining as much weight as she should have"

"She spits up on to two times a day. Sometimes it seems like more volume than other times"

"On formula milk with Enfamil with Iron, then Prosebee, and currently on Nutramigen"

"Has good appetite"

Vital signs: T- 37.3C, P- 100 bpm, R- 30 cpm, BP- 90/60 mmHg, O2 sat- 97%

Length: 26" (66 cm) (50th percentile rank)

Birth weight: 7.8 lbs (3.5 kgs) Current weight: 12.8 lbs (5.8 kgs) (5th percentile)

Head circumference: 16.3" (41.5 cm) (25th percentile)

Celiac sprue- no antibody noted

Barium esophagram- normal size, contour, swallowing, peristalsis and movement of material through
esophagus

Up and about, awake and alert

Head- no areas of tenderness, fontanelle is open and soft

Eyes- pupils respond equally to both direct and consensual light stimulation

Nose- nasal mucosa is pink and moist, with small amount of clear discharges, septum is in midline

Mouth- 2 teeth are present, gums are pale red, (-) ulcers, (-) exudates

Chest- symmetric, AP to lateral diameter is 1:2, no retractions and paradoxical movement

Lungs- clear lung sounds noted on both lungs, no adventitious sounds noted

Heart- no thrill or abnormal impulse is noted, (-) murmurs

Breast- symmetric, no thickening and alteration in vascular pattern, no discharge or supernumerary

nipples

Abdomen- symmetric, with bowel sounds noted 10-15 times per minute, no bruit or friction rub are
heard, no tenderness on palpation, liver dullness is 4 cm, the area of dullness descends 2 cm on
inspiration, tympanitic sounds are heard

Genital- grossly normal, no discharges are evident

A
MALNUTRITION, MILD, PROBABLY SECONDARY TO GASTROESOPHAGEAL REFLUX DISEASE VS
MALABSORPTION SYNDROME

1. Will be managed as outpatient.

2. Increase caloric intake to 90-100 kcal/kg/day of ideal weight for height.

3. Increase calories in formula: 1 scoop of formula to 1.6 oz of water

4. Burp the baby after each feeding.

5. Initiate breastfeeding, if tolerated by both mother and baby

6. Zinc supplementation 20 mg OD x 14 days

7. Consider for blood chemistry determination, serum electrolytes, endoscopy, celiac panel (anti-tTg and
IgA), Sweat chloride test, serum protein and albumin

8. Review newborn screening results

9. If all results are normal, continue nutritional intervention

10. Initiate gradual introduction of solid foods, as tolerated

11. For possible referral to a multidisciplinary feeding program vs inpatient observation

The patient's weight is only 5.8 kg (expected weight of a 7 month old is calculate at around 8 kg) and the
patient's weight is on 5th percentile rank. Patient's length is 66 cm (on 50th percentile rank), and head
circumference is 41.5 cm (at 25th percentile rank). Based on the current anthropometric measurements,
the patient is currently undernourished or is having failure to thrive. The existing malnutrition is
probably related to inadequate caloric intake as manifested by the feeding difficulties of the patient and
since the patient is not on breastfeeding which is instead just receiving a formula milk (currently on
Nutramigen 4 or 5 ounces every 4 to 6 hours). This current condition of the patient is also probably
secondary to an underlying Gastroesophageal Reflux Disease as verbalized by the mother where the
baby "spits up about 1 to 2 times a day", however, swallowing studies revealed unremarkable finding.
Another etiology being considered is the possibiliy of a malabsorption sydnrome (such as celiac disease,
cystic fibrosis) thus, further tests are needed to rule out such conditions.