Toddler suffers from emesis and weight loss

Key Points

THE CASE

A 13-month-old girl with vomiting and cough is admitted through the emergency department for failure to thrive. The patient’s parents report that these symptoms began 7 months ago and have progressively worsened.

The girl was born prematurely (birth at 30 weeks' gestation) via spontaneous vaginal delivery to a G0P1 mother. Her birth weight was 4.5 lb, and the newborn screen was normal. The baby was discharged home shortly after birth without any medications. Initially she was eating well and growing appropriately on cow's milk formula. Solids were introduced at 6 months of age.

In addition, she has had chronic upper respiratory infection symptoms for the past 6 months despite treatment with antibiotics and nebulized albuterol. The cough is worse at night and is wet-sounding but nonproductive. Her rhinorrhea is clear. Her parents deny recent fever or sick contacts; however, 4 months ago she was hospitalized for 2 days for pneumonia.

Your review of the patient's systems is unremarkable. Developmentally, she has a 3-word vocabulary but is not standing yet. Her family history is also unremarkable. She is an only child. Her parents both work on a farm. There are no pets in the house, and there has been no recent travel. The patient's immunizations are up-to-date for 9 months only.

Physical examination

The child appears small for her age, and she is somewhat irritable. She is afebrile, her pulse is 102 beats per minute, and her blood pressure is 96/49 mmHg. Respiratory rate is 32 breaths per minute, and oxygen saturation is 98% on room air. The patient's weight is 13.2 lb, her height is 26 in, and her head circumference is 16 in; all of these values are below the 5th percentile for age even when corrected for prematurity, confirming failure to thrive. She had been growing along the 25th to 50th percentile for weight, height, and head circumference until 6 months of age, at which point her growth patterns started to decrease, first in weight, then height, then head circumference.

The patient's head is normocephalic without evidence of trauma or dysmorphic features. Anterior fontanel is open and flat. Conjunctivae are clear, and the sclerae are anicteric. The oropharynx is clear with moist mucous membranes. Nares are patent with clear discharge. Her neck is supple without masses. The chest is clear to auscultation except for diffuse rhonchi and occasional crackles at the right lung base. Respiratory effort is normal. The heart has a regular rate and rhythm without murmurs. The extremities are thin, without edema. Pulses are 2+ bilaterally. The abdomen is soft, nontender, and nondistended, without masses or organomegaly. She has normal external female genitalia. Her skin is warm without lesions. She has no lymphadenopathy. A neurologic exam reveals normal tone and no focal findings.

Differential diagnosis

The differential diagnosis at this point is quite broad (Table 1).^1-3 High on your index of suspicion is gastroesophageal reflux disease (GERD), which can present with poor weight gain, irritability, asthma, recurrent aspiration pneumonia, and upper-airway symptoms.

Something about this situation makes you hesitate. You remember that the prevalence of GERD typically peaks at 4 months and that most children tend to "outgrow" their reflux symptoms by 12 months of age.¹ An onset of vomiting after 6 months of age is unusual. In the setting of failure to thrive, proceeding to empiric therapy without diagnostic evaluation may not be wise.

You consider other esophageal disorders. Possible structural lesions include hiatal hernia, stricture, web, and obstruction by foreign body. A vascular ring, annular pancreas, or lymphoma can compress the esophagus and also cause dysphagia. An H-type tracheoesophageal fistula could explain the recurrent pulmonary symptoms. Esophageal dysmotility can be caused by achalasia, scleroderma, and muscular dystrophy.

It could also be related to food. Children with cow's milk protein intolerance can present with vomiting and failure to thrive and can develop asthma. Celiac sprue can manifest when gluten-containing foods are introduced at 6 months of age. Diarrhea is often more prominent with these disorders.

Finally, you consider rare conditions that can cause vomiting and failure to thrive such as cystic fibrosis, metabolic disorders, hyperthyroidism, immunodeficiency, chronic renal disease, and adrenal insufficiency. A brain lesion causing increased intracranial pressure could also be a possibility.