excess fat, mucus or blood in her stool, which may indicate a malabsorption syndrome. Less likely etiologies, but still worthy of consideration would be cystic fibrosis or subclinical congenital heart or lung defects, as yet only manifested as failure to thrive.
             Nursing management would include asking Tina to complete a one day log of all feedings given to quantify total caloric intake based on Ebony's needs. Since Ebony continues to breastfeed almost exclusively, Tina's caloric intake also needs assessment. This may be a good time to start the introduction of small feedings of cereal or vegetables for Ebony. If Tina feels that she cannot make dietary changes on her own, it may be a good time to discuss supplementation with an iron fortified formula. It would be helpful to know Ebony's temperament – is she high strung and colicky, a difficult child to feed? How does Tina feel about her current social and economic situation? Many times, life stressors and difficult family situations can lead to difficulty with feeding patterns. Did the first child also experience FTT? Have there been any reports to social welfare services about suspected abuse or neglect? This could be the time to identify any difficulties with abuse or drug or alcohol issues, and assist the mother in obtain the appropriate referrals for social services. 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.
             At this time, if the physical exam is unremarkable, no laboratory assessment beyond hematocrit is necessary. Any laboratory evaluation should be guided by history and physical, since less than 2% of testing...