Failure to Thrive in the First Month of Life

Family Medicine Specialist CMEPakse, Laos PDR,October 15-17, 2012

Objectives

•Using Case studies, understand the common causes of FTT in the first month of life

•Discuss the challenges of work-up and management of FTT in the community

Case #1

•A three day old infant is brought to your health clinic by her mother. She is not feeding well.

Discussion questions

•What do you want to ask about the feeding?

•What other questions do you want to ask the mother?

•What might be wrong with the child?

Facts

•Born at term in the village after a normal pregnancy

•Prolongued-20 hour -second stage of labour

•Mom had a “fever”•No meconium•Baby cried at the perineum and breastfed

immediately•Cord was cut and tied with string

Facts

•BWt: 3.1 kg, at the health centre day one•Babe fed frequently in the first 48 hours

then became disinterested•Only passed urine once today•Mom has not had any immunizations.•Baby has not been immunized

What is your differential diagnosis?

Differential Diagnosis

•Sepsis•Pneumonia•Meningitis•Respiratory illness•Cardiac failure•Renal failure

What would you look for on examination?

Examination

•Wt•Temperature•HR•RR•Level of consciousness•Fontanelle•Respiratory effort

Examination

•Heart sounds, pulses•Abdomen-BS, distension, umbilicus•Skin-rash, vesicles, pustules•Reflexes, tone, alert•Genitals, anus-discharge, rash

Facts•Baby is lethargic with a weak cry.•Wt 2.7kg•HR 180, RR 65, T-34.5 degrees•Fontanelle flat and soft. PERL. Decreased tone.•Mild indrawing but normal breath sounds•Cardiac exam normal aside from HR•Abdomen soft, not distened, decreased BS,

umbilicus clean and dry.•Small fluid filled pustules on trunk and right

arm

Questions

•What is the significance of the low core temperature?

•What is the most likely cause of the poor feeding?

•Are there any tests you would like to order ?

SEPSIS

•What is sepsis?•What organisms are the most likely?•How will you manage this infant?

Sepsis

• Infection that involves the entire body. •May present with subtle, non specific

changes in activity-change in feeding pattern, vomiting, pallor, poor tone, poor skin perfusion, irritability

•Lethargy, apnea, tacypnea, cyanosis, petechiae, early jaundice

•Fever or hypothermia (in first week),•Hypoglycemia or hyperglycemia, metabolic

acidosis

Early Onset Sepsis-Organisms

•E coli and other gram negative enterics•Group B streptococcus•Enterococcus

Management

•Stablize cardio-respiratory status.•Start an IV, start antibiotics ASAP•Arrange transfer to a larger centre. •WBC, Blood Culture if available•CXR•LP•Glucose, +- bili•Urine cultures

Management

•Antibiotics- Beta lactam and aminoglycoside-Ampicillin/penicillin and gentamycin

•Or Third generation cephalosporin-cefotaxime ,ceftriaxone, ceftazidime plus ampicillin (listeria and enterococcus)

•Consider Cloxacillin (pustules-staph aureus)

Community

•Are there ways you could work to reduce sepsis in your community?

•What other groups of patients are at risk for sepsis?

Case #2

•A three week old boy is brought to your health center by his mother. She is worried because he seems thin and has eye D/C.

What questions would you like to ask the mother?

Questions

•Pregnancy-illness, vitamins, prenatal care, gestation, chronic illness, diabetes, high BP

•Delivery-maternal fever, length of labour, fetal HR abnormalities, resuscitation

•Feeding, stools, vomiting,fever, behavior•Eye d/c details•Exposure to others with illness

Facts

•Preterm labour at 36 weeks gestation. Mom had only one prenatal visit. She has been ill with fatigue and cough.

•Birth weight was 2.1 kg•Eye D/C noted day after birth. Cleaning

with water.

Facts

•Breast feeding but milk supply is poor. Baby is feeding “all the time”.

• Stools once every five days, wets three times a day

•Not sure if a fever. Sometimes really sleepy-has to awaken to feed, then doesn’t stop feeding

•Mom is exhausted, flat affect, doesn’t seem too worried-she says her husband made her come.

What is the differential diagnosis?

DDX

•Breastfeeding failure•Maternal Post partum depression•Cardiac failure•Respiratory infection•Malabsorption

Physical examination

•What important things will you look for?

•Weight, HC, length, •Vital signs•Signs of dehydration•Fontanelle, eyes•Skin rash•Chest –crackles or wheezes•Heart sounds, murmur

Facts

•Baby is alert but thin, wasted•Wt 2.3 kg, HC 37cm•HR 120, RR 30, Temp 37•Yellow eye discharge bilaterally, no

conjunctival injection•Chest clear, HS normal, no murmur•Abdomen scaphoid•Skin is hanging on the legs•Fontanelle is sunken

How would you manage this patient?

Management

•ABC•Discuss mom’s mood-depression-

community services to help?•Advice re supplemental feeding•Eye drops-Erythromycin•Follow closely