Hot Seat Case #124: 15 month old with failure to thrive
Posted on: January 24, 2019, by : Haroon Shaukat MD
Haroon Shaukat, MD Children’s National Medical Center
with Joelle Simpson, MD Children’s National Medical Center
HPI:
15 month old ex FT male with no significant PMH who presented with his father after their WCC checkup concerning for no weight gain over the past 8 months. Father stated the PMD was concerned that the patient was the same weight at both 9 and 15 month visits with preservation in length/height. Parents reported occasionally he is a picky eater, but, otherwise had no concerns. Currently, the patient fits into 9-12 month clothes.
Diet History: Breakfast – 1 packet oatmeal, 6 oz whole milk
Snack – 2-3 crackers
Lunch – ½ can pasta, 6 oz whole milk
Dinnner – ½ can pasta, 4 oz apple juice
Snack – 6 oz whole milk
ROS: 1 month of looser stools, No fever, rash, irritability, vomiting, heavy breathing, nasal congestion, easy bruising
Past Medical Hx: None
Medications: None
Social Hx: Lives with mother and maternal grandmother. No travel or pets.
PE: T 37, P 132, BP 106/60, R 22, Sats 98% RA; Wt <5th %ile, Ht 15th %ile
General: Comfortable appearing but small for age HEENT: MMM, oropharynx nonerythematous
CV: RRR no murmurs or rubs. Cap refill <3secs.
Pulm: Good air entry bilaterally, no wheezing or crackles. No retractions
Abd: +BS, soft, non-distended, no HSM, normal genitalia
Neuro: Awake and alert, No focal deficits. Normal tone. Normal development
Skin: No rash, bruising, or pallor.
You notice a note in the patients chart from his PMD today requesting workup and admission for FTT. You call and speak with the PMD who faxes the growth chart and reiterates a good relationship with family and that they are reliable.
Upon review of the growth chart you confirm length preservation, however, at 9 months the patient was on the 15th%ile for weight, at 12 months the patient was on the 5th %ile, and today (15 months) he was below the 5th %ile.
CBC 10.6 > 9.8/31.6 < 404 (44 PMNs, 44 lymphs, 4 eos, 4 reactive lymphs) CMP, Mg, Phos normal except albumin 3.2
Thyroid studies and prealbumin pending
Urinalysis SG 1.002 and otherwise negative
Stool occult blood: same specimen POC was positive, lab was negative
Stool culture pending
CXR: normal heart size, mild right infrahilar opacities may reflect focal atelectasis or small focus of infection.
EKG normal
You speak with the pediatrician to update her on the results of the lab work and she still requests admission for diagnosis.
The inpatient team does not believe this patient meets any admission criteria and can be worked up as an outpatient as their leading diagnosis is FTT secondary to poor caloric intake. You are also getting pressure for a discharge vs admit disposition as this patient’s ED LOS has been several hours (he is a hallway patient and not taking up a room).
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If the outpatient pediatrician is unwilling or unable to perform the FTT workup as an outpatient (and since the patient has already failed “outpatient management”), this child really does meet admission criteria and observation of caloric intake to assure weight gain. Otherwise, we risk losing this vulnerable child to follow-up.
I’d also consider adding to the initial FTT workup in the ED a review of the newborn screen, HIV testing, immunoglobulin levels (to assess immunodeficiency and also IgA levels), and anti-tissue transglutaminase (TTG) antibody (to assess for Celiac disease).
Agree with Dewesh..I’d be very reluctant to discharge this patient home especially with an uncomfortable pediatrician. I was wondering if the head circumference was ever measured to see if it aligns with wt and ht.
The HC was not measured in the ED but from the PMD’s growth charts faxed in, it was appropriate
I agree with Dewesh. Who is going to do this workup if the PMD can’t? They need a nutrition consult and a feeding plan that seems at least semi-promising before they go home. It would be another story all together if you just noticed this poor weight gain, sent labs and had a PCP amenable to following this child up and obtaining any appropriate consultations.
Difficult when we are caught in the middle like this.
Does anyone have any good strategies to “convince” the inpatient team when you are stuck in the middle like this, beyond the already attempted “PMD is uncomfortable with following up this child without an answer”.
I think Dewesh said it already that the PMD doesn’t have the resources to complete the evaluation as an outpatient. Admission for further work-up as indicated, observation of feeding and nutritional counseling are all indicated.
Agree with comments above. I would also add additional labs once I got those CBC results
I favor outpatient evaluation, including a nutrition consult (not sure how to do this, but WIC offices have nutritionists), a 3-day food diary, bi-weekly weight checks, and a short-time horizon for seeing improvement before admission. Sharing a clear game plan with parents and PMD can provide a direction that feels more empowering than just discharging from the ED.
Interestingly this patient was already plugged into WIC, and their appointment with them a few days prior advised them to follow up with the PMD who ultimately advised the ED.
I like this idea but I would first like to see if the PMD thinks this family could even begin to do this. Just a review of the child’s current diet: whole milk, crackers, pasta, juice, oatmeal….almost zero vitamins or iron in this diet. It seems this family doesn’t have a good understanding of the nutritional needs of their child despite being in the WIC program.
I will echo some of the comments above in my confusion as to why the child does not meet criteria for admission. Ideally the pediatrician would have performed some of the labwork already as an outpatient and requested a direct admission to the hospitalist service. However, unless practice standards have changed since I graduated residency, children who have had appropriate pediatrician follow-up and have continued to fail to gain weight despite outpatient recommendations are admitted for calorie counting and weight monitoring to conclusively determine whether they have a calorie deficiency or potentially an organic reason for FTT.
A lot can be elucidated with an inpatient admission regarding parental interactions, potential neglect, oral aversions, etc. As Dewesh stated, this may be a missed opportunity to care for a vulnerable child who, objectively, has already had 8 months of abnormal development.
I would page the hospitalist attending directly. Not only do I find that understandably so it’s hard for our residents to fight push back from the admitting team, I do find it I am often able to come to a better plan when I talk one on one with the hospitalist attendings. In fellowship, you should say you are the supervising physician and or that you have spoken with fellow colleagues to help establish the clout you deserve. Finally there is nothing wrong with paging the hospitalist’s boss or talking with the charge doc. This is what they are there for. It always comes back to doing what’s best for the patient. If they are continuing to lose weight and the PCP does not feel comfortable doing the work-up, I think it is the right thing to do. Truthfully, this probably CAN and SHOULD be worked up as an outpatient, but anyone who has worked in this country’s medical system knows that is not actually how things function in the real world.
Agree with the above. I can’t really tell what the PMD has been doing between month 12 and 15 when it was already apparent there was poor weight gain, but if they feel they have optimized what resources they have outpatient, then inpatient is the next logical step. If there are things like WIC, nutrition visit to home, food diary, etc that haven’t been tried and PMD is open to new suggestions, that is a different story, but it seems like the PMD is telling you that they feel they are being pushed beyond their limits. I would admit, and agree with Jeremy’s idea of talking directly to the attending to try to express your concerns with discharge home.
Dealing with pushback when the admitting team doesn’t agree with admission is one of the most difficult things we do in Emergency Medicine. It is a delicate balance but keeping the patient’s best interest is always your guide. NEVER discharge a patient if you don’t feel comfortable with that decision regardless of your level of training. If a satisfactory alternative to admission can be arranged that you think is safe and can be followed through then by all means you can change your mind but only if there are assurances that follow-up is assured and a plan for return and admission if the outpatient treatment/ work-up is not working.
Some of my biggest mistakes (yes I’ve made them) in my career have been when I let someone who I perceived as having more authority than me, intimidate me into not admitting a patient or not ordering a work-up that I felt was indicated. Think of our safety nemonic STAR with consideration for escalation if needed. The adult ED physicians will usually request that the hospitalist come see the patient and discharge the patient themselves, this usually ends the debate. After working at CNMC for 12 years, I’ve only had to do this once and it worked.
I love all the comments above. Ultimately, I ask, what is best for this child? The PMD is asking for support, the patient is NOT thriving and, for me, it is unclear how concerned the family is about the child’s condition. Do they express frustration at attempting to get him to eat? Are they concerned that he is so much smaller than his like-aged peers? How empowered are they to navigating our health care system? For families at a loss, despite what I assume are the best efforts of the PMD, I would argue that an inpatient admission can help them to better understand a plan of care, demonstrate some improvement in weight with measured caloric intake and hopefully thereby empower families to see evidence of a strategy that works to improve their child’s condition. If the family expresses grave concern as well and have been trying everything to improve their child’s condition, then I am not sure how I can be assured that continued outpatient management would change anything. Ultimately, my end point for a hospital admission is to demonstrate SOMETHING that works to improve this child’s condition. That may be measured caloric intake, fortifying foods, NG feeds, developing a nutrition plan, teaching parents etc.