Markenzie Jean-baptiste

Pediatrics Clinical Correlations

5/9/2020

Differential Diagnoses

• Gastroesophageal Reflux Disease/inadequate food intake: Patient in last 6 months has unexplained weight loss, fallen to less than 25^th percentile for weight but height is not affected. Patient is a “picky eater” and only wants to eat mac and cheese. Diet hx is not fully presented in this case so would need to gather more history about social/economic status, access to health quality food, consumption of juices and snacks and child’s intake. Unlikely the dx since mother insist that pt eats a variety of foods, has normal exam and no GI symptoms and pt is still above 2^nd percentile for weight.
• Diabetes Mellitus- Patient presents with significant weight loss which commonly presents with diabetes. Unlikely the dx since pt did not present with hx of polyuria, polydipsia or possible illness due to diabetic ketoacidosis.
• Celiac Disease: symptoms commonly appear between 9 and 24 months and poor weight gain. Unlikely the dx since pt does not have chronic diarrhea, abdominal distension/pain, and vomiting after the introduction of gluten-containing foods
• Inflammatory bowel disease: PT has slow weight gain. PT only wants to eat a specific meal,”mac and cheese.” Unlikely the dx since pt does not have any noted oral lesions, abdominal pain, gas, diarrhea and has a normal exam. Also, peak incidence is usually between 15 and 25 years of age
• Cystic Fibrosis: patient has slowed weight gain. Only wants to eat mac and cheese. Unlikely the dx since pt does not present with GI symptoms/ respiratory issues but further workup would be needed.

I was able to exclude other diagnoses like Tuner Syndrome, Down Syndrome and Growth Hormone Deficiency/dwarfism for now since patient prior to and currently is above the  2^nd percentile for weight, height and head circumference and has normal exam. According to CDC, less than 2^nd percentile for height is considered short stature and weight would be considered low weight-for-length. PT is currently slightly less than 25h percentile for weight.

Work up:

Initial tests

CBC, CRP and ESR– screen for anemia, chronic infection, inflammation and malignancy.

CMP—screen for an abnormal electrolytes, blood urea nitrogen/ creatinine, glucose, calcium, phosphorus, magnesium, albumin, total protein, liver enzymes, amylase, lipase. To evaluate kidney/renal tubular acidosis, liver, pancreatic function and they also provide an indication of nutritional status.

Urinalysis and culture–screen for protein or carbohydrate loss in Diabetes type 1 or any renal disease

Stool studies including guaiac, leukocytes, and calprotectin if inflammatory bowel disease (IBD)/malabsorption

Sweat chloride test- to r/ cystic fibrosis

Tissue transglutaminase and serum immunoglobulin (Ig)- screen for celiac disease

Treatment:

• The management of this patient will be based off the initial tests I have conducted. If there are any abnormal test results, these would be treated.
• Dietary intake will need further assessment. Nutritional counseling may be needed to promote quality healthy foods. Beverage intake should be discussed to see if child is consuming too much juices/snacks instead of nutrient dense foods. Conversation about supplements, multi-vitamins and minerals may be needed if child is not able to eat enough nutrient dense foods to gain weight.
• The child’s height, weight and BMI should be monitored closely to see positive changes accomplished within a three to six-month time frame.
• If all tests are normal and child does not improve with dietary monitoring within 3-6 months, then would consider further workup with advanced testing like TSH- to assess for thyroid disorders as hyperthyroid can cause weight loss,  PPD/chest imaging to r/o TB, serum ANA for auto immune disease, hepatitis panel, advanced endocrine eval for growth hormone deficiency, advanced imaging all based off how child progresses

 

Conclusion:

Based off the history of the patient and having above 2^nd percentile in height, weight and head circumference, and normal physical exam I believe the patient to have a normal presentation. According to UptoDate, children between the ages of two and five years may become “picky” or “selective” eaters. The child’s picky eating and wanting mac and cheese most likely is part of a temporary developmental phase and related to a normal pattern of slower growth for him at this age.

 

Source:

1.https://www.cdc.gov/nccdphp/dnpao/growthcharts/who/using/assessing_growth.htm

2.https://www-uptodate-com.york.ezproxy.cuny.edu/contents/eating-disorders-overview-of-epidemiology-clinical-features-and-diagnosis?search=avoidant%2Frestrictive%20food%20intake%20disorder%20(ARFID)&source=search_result&selectedTitle=1~3&usage_type=default&display_rank=1#H262927146

3. https://www-uptodate-com.york.ezproxy.cuny.edu/contents/dietary-recommendations-for-toddlers-preschool-and-school-age-children?sectionName=Preschool%20children&search=avoidant%2Frestrictive%20food%20intake%20disorder%20(ARFID)&topicRef=2877&anchor=H10&source=see_link#H10
4. https://www-uptodate-com.york.ezproxy.cuny.edu/contents/cystic-fibrosis-clinical-manifestations-and-diagnosis?search=avoidant%2Frestrictive%20food%20intake%20disorder%20(ARFID)&topicRef=2877&source=see_link