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Morning Report

Case Presentation
APRIL 1, 2019
Case: Initial Presentation
5 month old previously healthy term male directly admitted for failure to thrive work-up after failing outpatient
management.
HPI:
- PCP concerned patient has only gained 4 ounces in last month
- Mom reports long-standing issues with feeding
◦ Good latch but “falls off” after 1-2 minutes
◦ Refuses bottles
◦ Previously had success with SNS but recently has refused to take milk via SNS
- Does not get sweaty or appear tired with feeds; no cyanosis or diaphoresis.

PMH:
- Term, uncomplicated pregnancy and nursery course
- ED visit 3 months prior to admission for BRUE
◦ Baby crying and appeared pale with acrocyanosis
Case: Initial Presentation
Admission Examination:
VS appropriate for age
General: Alert, no acute distress, playful and interactive.
HENT: Unremarkable
Lungs: Clear to auscultation. no increased work of breathing
Heart: Normal rate, regular rhythm, 2/6 systolic murmur at LSB [c/w innocent murmur], 2+ peripheral
pulses. Normal cap refill and no cyanosis.
Abdomen: Soft, non-tender, non-distended, normal bowel sounds. No HSM.
Musculoskeletal: no edema
Skin: Skin is warm, dry and well perfused, no rashes or lesions
Neurologic: Alert, grossly normal.
Growth Chart:
◦ HC 6th %ile (Birth 21st %ile)
◦ Length <3rd %ile (Birth 23rd %ile)
◦ Weight <3rd %ile (Birther 30th %ile)
Common Conditions
◦ Abnormal Feeding
◦ Baby—poor coordination, hypotonia, latch issues,
congenital abnormalities (cleft)
◦ Parent—latch issues, low supply, incorrect formula mixing

Case: ◦ Infection
◦ GI Disorders
Differential ◦ GERD—Minority with related feeding refusal, inadequate
caloric intake
Diagnosis ◦ Pyloric Stenosis
◦ Milk Protein Allergy (about 2% of children <4 years)
◦ Child Abuse/Neglect
◦ Social Factors
◦ Food insecurity
◦ Inadequate housing/access to care
Case: Differential Diagnosis
Life-threatening or Serious Conditions
◦ Congenital Heart Disease
◦ Intermittent Intestinal malrotation
◦ Inborn Errors of Metabolism
◦ Intestinal Malabsorption (congenital chronic diarrhea)
◦ Kidney Disease/Failure
◦ Cystic Fibrosis
◦ Malignancy
◦ Neuroblastoma
◦ Nephroblastoma
◦ Acute leukemia
Case: Work-up and Diagnosis
On HD1, patient re-examined and the following anomalies found:

• Harsh 4/6 midsystolic murmur audible throughout precordium with palpable thrill
• Hepatomegaly (5cm below CM)

Cardiac Work-up:

• ECG: RA enlargement, Biventricular hypertrophy, Nonspecific T-wave anomalies


• CXR: Mild cardiomegaly with significant engorgement of the pulmonary vasculature
• Echo: Double-inlet left ventricle with left-sided outflow chamber, mild PS, dilated LV, left-
sided bulboventricular foramen with flow to aorta via BVF.
• Cath: Double-inlet single ventricle, L-malposed great arteries, PFO
Case
Physiology—Why acyanotic?
◦ Single Ventricle pathologies usually have cyanosis (full mixing in
common ventricle)
◦ Cyanosis depends on pulmonary blood flow
◦ Normal heart
◦ Qp = Qs (1:1)
◦ This heart
◦ Qp >>> Qs (4.9 : 1)
◦ Lungs received ~5x more blood flow than bodycommon ventricle effectively
received 5x more oxygenated blood than deoxygenated bloodalmost fully
oxygenated blood out of aortanormal sats
◦ Minimal PSminimal cyanosis
◦ Significant PSsignificant cyanosis
Failure to Thrive in Infants: Evaluation
History
Have a system for your differential
Three Categories—Intake, Expenditure, Malabsorption/Abnormal Metabolism
Common vs Life-Threatening
History should systematically evaluate each realm on the differential
Intake Issues—Feeding frequency, quality, latch, formula mixing, reflux, wet diapers/stools, etc
CHD—Feeding difficulties, cyanosis, easy fatigability, fussiness
IEM—Lethargy, abnormal movements/seizures, abnormal odor, abnormal appearance compared to other kids, etc
GI Issues—Diarrhea since birth, bilious emesis, projectile emesis, prolonged jaundice, urinary frequency, bloody stools
Infection—Fevers, sick contacts, frequency of past illnesses
Malignancy—Pallor, bruising, LAD
Social—Access to food, other kids at home, PCP, etc
Failure to Thrive in Infants: Evaluation
Exam
General: Fussiness, Arching (GERD/Sandifer syndrome), Hygiene, Bruising, Abnormal odor (IEM)
HEENT: Weak suck, Cleft, Abnormal coordination
CV/RESP: Resting tachypnea, murmur, asymmetric pulses (CHD)
ABD: Distention + tenderness (Malrotation, Volvulus), Olive mass (Pyloric Stenosis), Palpable bladder (PUV
in males), Flank masses (Neuroblastoma/Nephroblastoma)
SKIN: Bruising, Jaundice (Hepatic dysfunction, IEM, TORCH infections)
GU: Ambiguous genitalia (CAH)
NEURO: Hypotonia, seizures, asymmetric reflexes
Failure to Thrive in Infants: Evaluation
and Initial Management
Further Work-up depends on History and PE
Labs
CBC (Anemia, malignancy, infection)
CMP/RFP (CAH, malnutrition, dehydration, liver dysfunction, kidney injury)
Glucose
Preliminary metabolic labs (lactate, ammonia, CBG, urine organic acids, plasma amino acids, acylcarnitine profile)
Urinalysis
Cultures
Imaging/Studies
ECG, CXR, +/- Echo (CHD
ABD US/Upper GI (Malrotation, Volvulus)
Swallow Study
Skeletal Survey
***Most patients can be observed for the first 12-24 hours to evaluate feeding if History and PE are
not concerning for another cause***
Failure to Thrive in Infants: Evaluation and
Initial Management
SEE UPTODATE ALGORITHM
Case in Review
Since Diagnosis
s/p PA banding at 6 months
s/p Bidirectional Glenn at 9 months
On sildenafil for pulmonary hypertension (likely related to initial
pulmonary overcirculation)
Take Home Points
History and physical exam skills still matter

Apply a systematic approach to all cases of FTT

Not all serious CHD will present in the first days of life

A lack of cyanosis does not rule out serious CHD


References
Park MK. Park’s Pediatric Cardiology for Practitioners, 6th Ed. Elsevier
Saunders. 2014
Everett AD, Lim DS. Illustrated Field Guide to Congenital Heart Disease
and Repair. Scientific Software Solutions Inc. 2010
Caglar D. Evaluation of Weight Loss in Infants Six Months of Age and
Younger. UpToDate. 2019.
Ficicioglu C, An Haack K. Failure to Thrive: When to Suspect Inborn Errors
of Metabolism. Pediatrics 2009; 124:972.