1. Failure to Thrive in the First Month of Life Family Medicine Specialist CME Pakse, Laos PDR, October 15-17, 2012

2. 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

3. Case #1 A three day old infant is brought to your health clinic by her mother. She is not feeding well.

4. 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?

5. 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

6. 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

7. What is your differential diagnosis?

8. Differential Diagnosis Sepsis Pneumonia Meningitis Respiratory illness Cardiac failure Renal failure

9. What would you look for on examination?

10. Examination Wt Temperature HR RR Level of consciousness Fontanelle Respiratory effort

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

12. 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

13. 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 ?

14. SEPSIS What is sepsis? What organisms are the most likely? How will you manage this infant?

15. 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

16. Early Onset Sepsis-Organisms E coli and other gram negative enterics Group B streptococcus Enterococcus

17. 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

18. 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)

19. Community Are there ways you could work to reduce sepsis in your community? What other groups of patients are at risk for sepsis?

20. 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.

21. What questions would you like to ask the mother?

22. 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

23. 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.

24. 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.

25. What is the differential diagnosis?

26. DDX Breastfeeding failure Maternal Post partum depression Cardiac failure Respiratory infection Malabsorption

27. Physical examination What important things will you look for?

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

29. 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

30. How would you manage this patient?

31. Management ABC Discuss mom’s mood-depression-community services to help? Advice re supplemental feeding Eye drops-Erythromycin Follow closely