Hi,
I just wanted to run this by this group of professionals to see what y'all
thought.
Pt. is 13 month old female, dx'd by pedi with mild FTT at 9 months well
child checkup. Up until 6 months, baby had been thriving along 5th
percentile (mom is 5'0", dad 5'10"). Weights are as follows:
birth: 5# 3 oz.
2 m: 7 #
4 m: 9 # 6 oz.
6 m: 12 # 4 oz.
9 m: 12 # 3 oz.
Length and HC within normal limits, at 5th and 25th percentile,
respectively.
Baby born via uncomplicated SVD at 37 1/2 weeks, induced secondary to IUGR,
as determined by serial U/S showing baby falling off fetal growth curve.
Pregnancy otherwise uncomplicated, delivery without meds x pitocin.
Social and motor milestones up to 6 months within normal limits. At 9
months, social milestones were met but baby not sitting up yet.
Mom exclusively bf'd up to 9 months, on demand. This is 2nd baby for mom,
first baby (preterm at 35 weeks) bf'd for 14 1/2 months, thrived, no
medical issues, except cow's milk allergy dx'd when child was a toddler.
Mom is lactose intolerant, father is not. No other fam hx of food
allergies. Other history: baby has intermittent exotropia, followed by
pedi ophtho, and has atopic dermatitis only on cheeks and ear lobes,
responsive to Protopic.
At 9 m visit, PE was otherwise normal except baby's inability to sit up.
Muscle tone normal.
Mom told to push solids, do pre/post feed weights, which revealed baby
taking anywhere between 1 oz. to 6 oz. per feed, baby feeding about 8-9
times per day. Baby not happy with solids but after persuasion, tolerates
1- 1/2 T. of solids per meal, about 2 meals per day. Mom continuing to bf
on demand.
Pedi neuro consulted, normal neuro exam. MRI of brain recommended to r/o
lesions, deferred by parents. Thought that baby needs muscle mass to
develop normally, confirming need to work up cause of FTT.
Labs done, all with normal results: chem 7, AST, ALT, Albumin, thyroid
panel, CPK, CBC, stool studies, cath urine normal, metabolic studies
repeated, all normal.
After 6 weeks of pushing solids, baby gains 9 oz. Everyone happy for the
time being. However, 6 weeks later, at 12 m. visit, baby only gained 4
oz., so is now 13 #. Pedi recommends one can of Pediasure per day, which
baby will not tolerate.
Pedi GI consulted. Baby now 13 months, weight at GI office 12 # 14 oz.
Length and HC still normal. GI does thorough H&P and concludes that most
likely cause of inadequate caloric intake is food aversion, secondary to
either "breast as pacifier" or food allergies or both. Further down on the
differential is: esophagitis, constitutionality (highly unlikely per GI
but possible), and then even further down, celiac dz. and CF. Mom mentions
zinc deficiency and GI says that is also possible.
Explains to mom that when baby uses "breast as pacifier" she gets enough
milk to thwart hunger sensation, but not enough to sustain nutritionally.
Therefore, she does not feel hungry to eat solids. Recommends: feed
solids first, then try Pediasure, then offer breast. Decrease frequency of
feeds at breast. Try not to comfort nurse. Also recommended baby and mom
be completely off all milk products. Also gave rx for zinc.
If no improvement in 1 month, will rule out esophagitis, celiac and CF.
GI doc says that she is a bf advocate and bf'd her own children well past a
year. Did not specifically recommend weaning to increase solids intake.
Oh--parents are offering table foods to baby, trying higher caloric foods
like meat, avocadoes, etc.
So...any thoughts? Is this "breast as a pacifier" thing real? I have never
heard of it but I am no expert. Would decreasing feeds at breast help or
hurt? Baby very attached to mom, parents are AP style folks.
I should confess now that this is my baby. Any thoughts? I'm really
perplexed--and getting more anxious by the moment.
Thanks in advance,
Anh H. Gordon, MD (Family Practice, now SAHM)
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