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When a Child Does Not Grow

Malnutrition is the most important determinant of mortality and morbidity in young children worldwide; it is associated with 50 percent of all deaths in children under five years of age.

Nida (name changed) is 18 months old and was in our hospital this past week.  She weighs 5.5 kg (12 lbs).  According to WHO data, that puts her at the 0 percentile, age for weight.  (See chart below)  She weighs about the average weight of a 3 month old infant.  Imagine if your child went from 3 months of life to 18 months without growing?

Notice her size in comparison to a normal size pillow on the right
Nida’s weight for age in months, see black dot off chart (not between 3rd and 97th percentiles)

Unfortunately, we not too infrequently see patients like Nida.  Most times the patients come to us for other medical or incidental reasons.  Nida was in our hospital because she has bronchiolitis (viral infection of lungs).

Why or how does this happen?  It can actually be more difficult to detect than one would expect, and even further difficult to diagnose the reason.  Until very severe, the child can appear fairly average.  They just look like a younger version of what they should.  They essentially can blend in without detection.  I remember in Zimbabwe admitting children to the pediatric ward.  Sometimes I’d get through the entire process of writing their admit orders and evaluating them but it was not until I looked at their age that I realized they had severe malnutrition.  The child would look like an average 2 year old, but then I would see that they were actually 6 years old.  I would have to look at the age again to make sure I was not mistaken.  It wasn’t a lab test or a physical exam finding as much as just their age that was diagnostic.

Sure there are also physical exam findings that often accompany malnutrition, such as edema, muscle wasting, adipose tissue redistribution, the classic enlarged stomach appearance, etc…
The problem with relying on those findings is that there are other diseases that can mimic those findings.  An enlarged stomach could be an enlarged spleen from malaria.  Or it could be parasitic worm burden.  Edema could be a kidney problem.  Maybe its not even an edemetous type of malnutrition.  All the kids are thin, that doesn’t distinguish them.  A two year old with these findings is not nearly as worrisome for malnutrition if he is really two.  But if he is 6 and looks 2, that gets your attention.  It’s an age discrepancy that is the most glaring finding.

The Cassava plant:  In rural Honduras, mothers too often use to make a milk (“Yuca” milk) that is used to feed infants when their breast milk does not come in and they cannot afford formula.  It is starch based (like a potato) and contains no protein.  Its a frequent cause of severe malnutrition in our area.

Sometimes there are obvious medical reasons (chronic diarrhea, heart disease, lack of sufficient intake, etc) for lack of growth.  Other times there are confounding social reasons.  Sometimes social and medical reasons can coexist, but they don’t always bring the patient into the doctor.

Nida has clubbed feet and a small hole in her palate.  Could this be causing her to not grow? The palate hole has been evaluated and does not seem large enough to have such an impact.  The mother states she eats a normal quantity of food and has a normal diet. She does not have diarrhea.  Does she have another congenital anomaly that is being undetected and that is causing her to not grow normally?  When a child already has something “not normal physically” it certainly follows that there could be other possible explanations, but this also puts them at higher risk for social reasons such as neglect.

Nida’s hemoglobin is 6.9 (normal ~14).  That’s almost low enough to need a blood transfusion.  In an adult, we would order a transfusion at this level.  Sometimes we transfuse at this level even in children, depending on the scenario.  Nida’s heart rate is normal, meaning that she has gradually become anemic over time, and her body has had the time to compensate.  The most likely reason for her anemia is related to poor nutrition and iron deficiency.   Her body lacks the basic ingredients to create something as simple and necessary for life as an oxygen-carrying red blood cell.
Her hair is thinning out from malnutrition

Nida’s mother has been at her side since hospitalization.  She has feared returning home at times which made us think there was possible abuse in the home.  At the same time, when we have talked to her father, he seems very reasonable and caring, competent, and wanting to do what is best for her.  After interview evaluation by a Honduran psychologist, there was suggestion that the mother could be potentially trying to use the child as leverage against her husband, for unknown reasons.

It is all very unclear.  It’s hard to know who to believe and what to blame.  What we do know is that Nida is not growing.  Something is wrong.  Is she being neglected?  Is there a social reason or a medical reason, or both?
While the reason for Nida’s malnutrition may not be neglect, I am convinced that a significant portion of cases of malnutrition in the third world result from neglect.

We are thankful that Nida’s parents have decided to allow us to place her in the children’s home near the hospital for the next 4 weeks in order to try and figure out the source of her malnutrition.  There we will be able to exclude social reasons and monitor her dietary intake and food selection, while following her growth.

Please keep her in your prayers

-Isaac

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