Dear Wendy and Lactnetters,
I was concerned about the baby you wrote about with poor weight gain. It
sounded like a little more than routine allergy to me.  So I decided to ask
a good friend of mine for his opinion. Dr. Brian Riedel is a very
pro-breastfeeding pediatric gastroenteroligist. Until very recently he was a
professor at Vanderbilt School of Medicine in Nashville, as well as a
partner in a large practice there.  In Novermber he arrived here in Lima
where he will be ministering to the needs, both physical and spiritual of
street children.  I put a lot of stock in what he has to say.
I want to add a little note of my own. I think sometimes LCs have come
across as having a somewhat adversarial relationship with doctors.  I'm not
saying that's the case here, but I do think we as a profession need to
really guard against criticizing what the ped says.  Sometimes we do need to
suggest a second opinion, and that is completely within the realm of good
professional practice. But I think we need to be very careful that we come
across to the peds as serious minded health care professionals who respect
them and who are worthy of their respect.
I'd sure love to hear what happens with this baby. Isn't it great that we
have a forum like Lactnet to post our concerns and get all kinds of advice?
I'm really glad you posted, Wendy. Good luck in your studies!
Warmly,
Glenni Lorick, BSE, IBCLC
Lima, Peru
mailto:[log in to unmask]


-----Original Message-----
From:   Brian D. Riedel [mailto:[log in to unmask]]
Sent:   Jueves, 16 de Diciembre de 1999 10:56 p.m.
To:     [log in to unmask]
Subject:        RE: Poor weight gain?

Glenni,
I looked at a growth chart on this child and it's alarming, so I don't think
it's fair to say "except for a number this baby's fine".  Pediatricians
diligently plot growth charts for a reason - they give great integrated,
overall info about well-being.  Yes, it's true that many babies adjust
several channels on the growth chart (up OR down) during the first 6 months
of life, since what they're born with has to do with intrauterine factors
and what happens after birth is more reflective of genetic growth potential.
However, there is a limit and it's NEVER okay in the first year or two of
life to lose weight over the course of several months, which this child has
done.  She's gone from 95% to 50 to 25 to ~5%ile and losing at last check.
The comment that height is still increasing doesn't reassure me as A) in
malnutrition, weight gain always falls off before linear gain does; B) that
only exaggerates the wt/length ratio which is a pretty good barometer.  I
can't imagine that the baby has rolls of fat all over with those numbers -
if so, it's time to recheck the weight measurements and recalibrate the
scales.  Otherwise, there's no question that something's up.
I think one would have to consider several possibilities - arranged in broad
categories as 1) decreased intake/absorption; 2) increased output/losses; 3)
increased metabolic demands (rare).  With the history which strongly
supports both true dietary protein intolerance (bloody stools, improved w/
dietary manipulation) and gastroesophageal reflux (vomiting could be due to
either diagnosis), these are high on the list.  Many babies continue to have
reflux to the some level even after overt spitting/vomiting stops, leading
to restriction of intake due to esophagitis.  Similarly, I've seen many
cases of malabsorption due to dietary protein intolerance (allergy may
actually be an imprecise term in this context) after the blood is gone from
the stools.  Either of these can lead to poor growth alone or in
combination.  Of course, other diagnoses need to be considered as well.
I would agree that more investigation is in order since this is not simply a
"slow starter" but rather a "crash and burn-er" based not on a gut reaction
but on the data.  You know the importance of good nutrition during the
critical first 2 years of life when we're getting our critical cell mass in
a number of vital organ systems, esp the CNS.  Most ped GI docs are quite
familiar w/ normal infant growth (that's their job), so that seems like an
unfair comment.  Call me an aggressive subspecialist looking for pathology,
but from this distance, based on limited info, it sounds like the family's
getting sound advice.  My humble opinion - you asked for it :-)
Brian
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