Mastering Pediatrics: Failure to Thrive

Advancing Learners Pediatric Clinical Reasoning and Knowledge

Key Points


    Growth parameters are important vital signs for children and teenagers and in children we monitor weight, length and head circumference. Pediatricians may seem obsessed with growth parameters as we are always evaluating them for every clinical encounter.

    Importantly, if a child is growing well, then likely they actually are well and do not have significant underlying disease. When the growth parameters are not tracking, then the reason for that needs to be elucidated.

    Failure to thrive means persistent weight below the 3rd percentile for age in infants and young children or that the rate of weight gain is significantly below expected standards for their age and sex.
    Failure to thrive does not mean that the child is small if they are growing at the appropriate velocity for their age, gender and genetic potential. Two good references for growth velocities can be found Guo et.al., DOI: 10.1016/s0022-3476(05)82045-1 and Kalberg et.al., DOI: 10.1016/s0022-3476(05)82045-1

    Not gaining weight usually is due to three major categories:

    • Not enough calories getting into the body, e.g. not eating enough, regurgitation, serial or multiple illnesses
    • A processing or metabolic problem within the body, e.g. increased metabolic needs like fever, significant trauma, etc.
    • Food not being absorbed for some reason, e.g. diarrhea, inflammatory bowel disease, short gut syndrome, etc.

    The cause may be easily identified (e.g. child with oral aversion), or quite often is multifactorial with more than one of these major categories being involved.

    Evaluation includes a comprehensive history, physical exam and at least basic laboratory testing. It may include more extensive testing, including a bone age for the child. A social history is always important to determine if there is unrecognized food insecurity within the household, different types of feeding practices or beliefs where the child may not be being provided adequate nutrition, or if there is frank child neglect.

    Treatment starts by trying to identify and treat the underlying causes. Increasing calories in an appropriate manner for the age, circumstances, and personal and cultural preferences is also usually started. For example, increasing the caloric density of breast milk or formula for infants, calorie boosting for older children and teenagers by adding calorically dense foods to the diet (e.g. often dairy products, oils, nut butters, additional protein, etc.). Nutritional supplements (i.e. Pediasure® Ensure® Carnation Instant Breakfast®) can also be used. For some special needs children, enteral feeding is needed. Those with some type of oral aversion can also work with feeding specialists.

    Food is expensive and special diets can add to the costs which can be financially difficult for families. Social workers may be able to identify additional food, financial and other resources to assist the family.

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Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Mastering Pediatrics: Fever

Advancing Learners Pediatric Clinical Reasoning and Knowledge

Key Points


    Fever not only makes children and teenagers feel bad. Parents really dread fevers because they worry about what is causing the fever, and kids being sick disrupts the entire household.

    A true medical fever is >100.5F or 38C. Parents will often think that any temperature more than 98.6F or 37.5C is a fever, but this is a temperature elevation.

    Most fevers are usually caused by an acute, self-limited illness, that can be treated at home such as a viral illness. Sometimes it is a bacterial illness such as an ear infection or strep throat that needs antibiotic treatment. Fever has a very large differential diagnosis and can always be the sign of a significant disease process.

    Assuming that there is a self-limited illness parents can be educated saying something like the following:
    Fever is a good thing. It is telling us that the body knows there is something wrong and is trying to take care of the problem.
    But fever can make the patient feel bad. Patients do not want to drink, they are in pain, or they just have that non-specific, “I don’t feel good” or “oogly feeling”.
    If fever is causing real discomfort then it can be treated with antipyretics like acetaminophen or ibuprofen. It will make the child feel better.
    But just because the patient has a fever they do not have to be treated with antipyretics. If they are acting well, they can just be watched. Antipyretics are there for the patient’s comfort.

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Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Mastering Pediatrics: Diarrhea

Advancing Learners Pediatric Clinical Reasoning and Knowledge

Key Points


    Diarrhea is usually defined as loose, watery stools that are more than 3 times a day, or much more than the usual frequency for the person. Usually this equates to a Bristol Stool Scale of 6 or 7.

    The differential diagnosis is large, but often is infectious with one of the most common causes being viral enteritis.Usually diarrhea is short-lived with resolution in a few days.

    An important point to remember that viral enteritis is the most common cause of bloody diarrhea overall. Blood in the stool is more likely to occur in any given case with bacterial diarrhea like Salmonella, Shigella, Yersinia, Campylobacter, Clostridium, and E. coli or parasitic infections like Entamoeba. However these infections do not happen as often as viral enteritis. Although bloody diarrhea is less likely to occur in any given case of viral enteritis, there are so many more viral infections than bacterial or parasitic infections, that the viral enteritis is the most common cause of bloody diarrhea.

    Gastroenteritis is not the same as enteritis and gastritis. Enteritis is the diarrhea; gastritis is the emesis. If the patient has both then it becomes gastroenteritis. This is important because the differential diagnosis is different for all 3 problems. There is much overlap though.

    Especially in children, patients can become dehydrated quickly with ongoing fluid losses. Evaluation of hydration status needs particular attention. Objectively weight changes are the best data sources. Physical examination findings such as slow capillary refill, poor skin turgor, and tacky mucous membranes also help with hydration evaluation. Urination is also a helpful measure by noting its frequency and sometimes its volume. It can be difficult to tell if a child has urinated because of mixed urine/stool, especially in diapered children. One can try to place cotton balls to create a “diaper dam” between the urethra and anus to try to identify urination frequency. In males, the penis can also be pointed toward the top of the diaper and that area checked for urine as it is less likely to be contaminated with stool.

    It is notoriously hard to evaluate stool volume. Most people are not diapered and even if they are weighing the diapers is very hard to do. Estimations of stool frequency through how many toiletings or diaper changes can assist. If diapered, volume can be estimated if parents describe them as “a blow out” or leaking outside the diaper.

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Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Mastering Pediatrics: Cough

Advancing Learners Pediatric Clinical Reasoning and Knowledge

Key Points


    Cough is a frequent problem that parents come to seek help for. The differential diagnosis of cough is large, but cough often starts because of an infectious disease like upper respiratory infections (URIs) with cold-like symptoms, bronchiolitis, pneumonia, seasonal allergies, bronchospasm or asthma. Congenital anatomic problems in infants (e.g. tracheoesophageal fistula, etc.) and aspiration in children with special needs are just some of the more common causes.

    Parents worry about the cough because it can cause sleeping problems in children and therefore the parents also get awoken themselves. Parents also complain that the “child is always coughing” or the “cough never goes away.” Multiple, serial, URIs can make it seem like the child is always sick. For children who are in child care or are early school age, it is not uncommon for them to catch one URI and then by the time the coughing is improving, two-several weeks later, the child catches another URI and the process begins again. Normal healthy children have 4-8 coughs or colds/year that last a week or longer, so they likely seem sick all the time to parents.

    Coughing also can last a long time. The body has many ways to keep itself healthy and to rid itself of disease. Lungs are like a damp sponge. They have some fluid which helps to clean out the airways. The fluid moves by ciliary action and chest wall movement. When there is an infectious process or the lungs are irritated, they make more fluid. There is more fluid to move which can build up in areas. Coughing helps to keep the fluid moving and keep the airways clear. Coughing is highly protective for the patient. If the airways are not protected then airflow can be diminished or cut off. The body knows this is not good and tries to clear the airway. This protective mechanism of coughing can continue for a long time after the infection or irritation of the lungs actually stops. There can also be lung inflammation occurring that is not perceptible to the patient – they feel fine and their examination is normal – but there still is inflammation going on. Therefore, coughing can still be occurring.

    Treatment for cough is treating the underlying cause along with symptomatic treatment. Humidified air, frequent moistening of the mouth/nose by sucking on lozenges or saline, nasal suction and adequate overall hydration can help. Honey can be used in patients > 1 year old to help soothe the mouth and throat. Children under age 1 are at risk of botulism so honey is not recommended for them. Over-the-counter cough medications are not recommended for children < 4 years old. Antipyretics for discomfort can also be used especially if there are other symptoms that are bothering the child.

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Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa