Ebony and Amelia FTT
Several elements in the history present as possible causes of Ebony's failure to thrive (FTT). In a multivariate analysis, FTT between birth to 8 weeks of age is associated with maternal prenatal factors (such as a lack of transportation, socioeconomic class) and infant postnatal factors (weak sucking). While Ebony has had no significant physical symptoms, the birth weight of 4.9 kg equals macrosomia which can sometime be associated with weak sucking and slow feeding, which in turn can result in smaller quantities being expressed per feeding session and an increase in maternal fatigue. It would be difficult to continue to breast feed exclusively while working full time, without personal transportation and with another child to care for, and Tina should be congratulated for her tenacity in attempting to continue to breastfeed. While working full time, Tina has still had difficulty affording food at times, and it may be that her caloric intake is not enough to sustain adequate breastfeeding for Ebony. Additionally, at six months it would be ideal to offer small solid feedings at six months, and it does not appear from the history that Tina has been able to start this yet. Several medical conditions could be contrib
Initially, both Amelia and Emily require a full physical examination with the following goals 1) identification of dysmorphology which may be suggestive a genetic disorder which could be effecting growth, 2) detection of underlying disease which may effect growth 3) signs of possible child abuse or neglect and 4) assessment for and severity of possible effects of malnutrition. Tina can be referred to the government's supplemental food program to obtain nutritious foods. It is important that all caregivers provide Ebony and Amelia with food which is well cooked and prepared in small pieces. At this point, Ebony is more mobile. Picture books or pictures from magazines can be fun at this age. It would be essential to review how Ebony is offered foods and what kinds of foods she likes and does not like. Tina's mother should also be interviewed to make sure she is also appropriately feeding the children in Tina's absence. Conditions which may contribute to Ebony's FTT which are not readily evident on physical examination include celiac disease, hyperthyroidism, chronic infection such as HIV, or metabolic disorders such as amino acid storage disorders. Since Ebony continues to breastfeed almost exclusively, Tina's caloric intake also needs assessment. The formula takes the father's height in centimeters, adds the mother's height in centimeters and divides it by two then subtracts 13 centimeters. Tina or the caregiver can look at the pictures with Ebony, pointing to the pictures and talking about what is in the pictures. Juice may decrease Ebony's appetite for foods which are better for her weight gain and muscle growth. Tina's health beliefs surrounding the care and feeding of her children should be investigated and her feelings given respect, since the intervention may be seen as an indictment of her ability to parent rather than an attempt to help her care for her children. If Tina, her caretaker and her mother can write down what types of food Ebony is eating and how much she eats over a three day period, it would be possible to quantify her average caloric intake and compare it to her needs. Parents often find it difficult to understand that the energy need in infants is three times that for adults in calories per kilogram.
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