FAILURE TO THRIVE
Clinical Challenge
You are seeing 15-month old Becka Pequena for her well child exam. Becka's growth curve is shown here.
On history you find that this baby was a healthy term baby in the 75% for weight, length, and head circumference at birth. She has not had any major illnesses in her life and has not had to be hospitalized. Her appetite is "OK" according to Mrs. Pequena. Becka weaned herself from the breast at about 10 months of age. She never really took to infant formula, so Mrs. Pequena started whole milk. The whole milk made Becka very constipated, so her mother started to give her some juice to help with the constipation. At presentation, Becka drinks about 24 oz of whole milk and 24 oz of juice a day and does not take vitamins or other medications.
A typical day consists of 1/4 cup of Cheerios with an 8 oz bottle of milk. Becka may snack on some of mom's eggs in the morning. She usually has a snack of fruit or 4-8 oz juice with some peanut butter or graham crackers before her morning nap. For lunch Becka may have a half a cheese sandwich or a jar of stage 3 baby food and 4 oz of milk. She generally drinks an 8 oz. bottle of apple juice at intervals during the afternoon, and may snack on some crackers or banana slices. For dinner, Mrs. Pequena gives her cut up table food (generally 1/2 cup meat and potatoes or rice) with another 8 oz. of milk. She has a bottle of juice or milk before bed time. Mrs. Pequena does not want to force her to eat but, she is concerned that she is not eating enough.
Becka lives with both parents and 4 year old brother. Becka's mother is 5'4 and her father is 5'7. Mrs. Pequena is unsure of the age of her home, but she describes it as "older." The house did have some pealing paint and was recently re-painted. Mrs. Pequena reports no severe stresses in the home. She does not believe her children have been abused by anyone-they are almost always with her!
The growth pattern shown is not unusual for breast fed children. The WHO has developed standard growth curves for breast fed children, which can be found here:http://www.cdc.gov/growthcharts/index.htm.
With this history of high milk intake and low food intake, Becka is at risk for iron-deficiency anemia, which may further depress her appetite. A CBC is warranted. Although the house that Becka lives in was recently painted, the old paint was peeling and it is an "older" home. Therefore, a lead level should be done. In fact, checking for anemia and lead poisoning is standard screening for 12 month well child checks. Becka's parents are both around the 25th percentile for height - a context which would imply that Becka's height is normal for her.
Becka should be followed in the next several months to see if the suggested changes to Becka's diet helped. Careful attention should be paid to psychosocial and environmental parameters, but at this point a referral to CPS is not warranted.
