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Case: 9-month-old girl with faltering growth (failure to thrive)

Clinical summary: Birth weight 3.0 kg (50th centile), now 5.8 kg at 9 months with progressive centile crossing downward. Length 67 cm. Exclusively breastfed but only 2-3 feeds/day due to working mother.

1. Most Important Clinical Finding

Faltering growth (failure to thrive) with progressive centile crossing downward.
At 9 months, the expected weight for a girl is approximately 8.0-9.0 kg (50th centile). At 5.8 kg, this child is significantly underweight. She started on the 50th centile and has crossed multiple centile lines downward - this is the hallmark of faltering growth and is the single most important finding.
The length of 67 cm is also below expected (~72 cm for a 9-month-old girl on the 50th centile), suggesting the growth faltering may be affecting linear growth as well.
Per the Harriet Lane Handbook (p. 756):
  • Underweight in children <2 years = weight for length/height <5th percentile
  • Progressive centile crossing downward across two or more centile lines is a recognized risk factor requiring urgent investigation

2. Possible Causes

Causes are best classified into three categories:
A. Inadequate Intake (most likely in this case)
  • Insufficient breastfeeds - only 2-3 feeds/day when a 9-month-old requires 6-8 breastfeeds/day for adequate caloric intake
  • Failure to introduce complementary feeds at 6 months
  • Poor feeding technique or latch
  • Maternal milk supply failure
  • Food insecurity
B. Increased Demand / Hypermetabolism
  • Congenital heart disease (one of the most common organic causes in infants)
  • Cystic fibrosis
  • Chronic infection (TB, HIV)
  • Inborn errors of metabolism
C. Malabsorption / Excessive Loss
  • Celiac disease (though usually manifests after gluten introduction)
  • Cow's milk protein intolerance
  • Chronic diarrhea
  • Inflammatory bowel disease
D. Psychosocial
  • Maternal depression or emotional distress
  • Child neglect / abuse
  • Social deprivation / poverty
(Harriet Lane Handbook, p. 762 - Differential Diagnosis of Malnutrition)
Most likely here: The inadequate feeding frequency (2-3 vs. 6-8 feeds/day needed) is almost certainly the primary driver - this is nutritional/social faltering growth, not organic disease.

3. Approach to Assessment

History:
  • Full feeding history (see Q4 below)
  • Stool pattern (frequency, consistency - diarrhea suggests malabsorption)
  • Vomiting / reflux
  • Respiratory symptoms (cystic fibrosis, cardiac disease)
  • Developmental milestones
  • Family history of growth disorders
  • Social history: housing, finances, maternal mental health, support at home
Physical examination:
  • Plot weight and length on WHO growth charts (required for <2 years)
  • Assess for signs of malnutrition: fat loss (orbital, buccal fat pads), muscle wasting (temporalis, quadriceps), edema
  • Micronutrient deficiency signs: pallor (iron), widened wrists (Vit D), dermatitis (zinc)
  • Cardiac examination: murmur, tachycardia, hepatomegaly (congenital heart disease)
  • Dysmorphic features (chromosomal or metabolic syndrome)
  • Signs of neglect or abuse
Investigations (targeted, not exhaustive at first visit):
  • FBC - iron deficiency anaemia is extremely common here (exclusively breastfed >6 months = major risk factor)
  • U&E, LFTs, TFTs
  • Urine dipstick/MCS
  • Consider coeliac screen, sweat test if malabsorption features present
  • Chest X-ray and ECHO if cardiac cause suspected
Catch-up growth calculation (Harriet Lane, p. 761-762):
  • Determine ideal weight for height (50th centile)
  • Multiply RDA calories for age × ideal weight ÷ actual weight
  • This gives daily catch-up caloric requirement

4. Important Dietary History

This is the most critical part of this case:
QuestionWhy It Matters
Number of breastfeeds per day and duration of each feed2-3 feeds is grossly insufficient; 9-month-old needs far more
Has complementary feeding started?Should begin at 6 months; absence = major caloric gap
What complementary foods are offered?Assess caloric density, variety, texture appropriateness
Is any formula supplementation used?May indicate poor breastmilk supply
Any bottle refusal, breast refusal, or feeding aversion?Behavioural cause
Who feeds the child and how?Feeding technique, responsiveness to hunger cues
Signs of adequate milk transfer at breast?Wet nappies, satiety after feeds
Any recent illness causing feeding difficulties?Acute vs. chronic problem
Mother's diet, stress, rest, hydrationAffects milk supply
Does mother express milk while at work?If not, milk supply falls due to reduced stimulation
Key point: In an exclusively breastfed working mother offering only 2-3 feeds/day, the most important dietary history question is: What happens to feeding while the mother is at work? - If the mother is not expressing milk at work AND not offering complementary foods, the infant is receiving drastically inadequate calories during daylight hours. This represents a feeding insufficiency with a social/circumstantial cause that is fully correctable.
Summary / Action plan:
  1. Urgent dietetic referral for calorie-dense complementary feeding plan
  2. Advise increasing breastfeed frequency or supplementing with expressed milk/formula
  3. Mother counselling on breast expression while at work
  4. Rule out organic causes (especially iron deficiency and cardiac disease)
  5. Social work involvement if food insecurity or safeguarding concerns
  6. Close follow-up with weight checks every 2 weeks
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