What Causes Weight Loss?

Patient Presentation
A 9-week-old female came to clinic for an evaluation of weight loss. She was a full term infant with a birth weight of 2.36 kg, and at her 2 week checkup she was 2.58 kg. She presented to her private physician for her 2 month health maintenance examination and had a weight of 3.2 kg (which was decreased from an urgent care visit) and was referred for further evaluation. She was fed formula 2-3 ounces every 2 hours with one stool/day. Since birth she had a history of dribbling formula from her mouth 1-2 times/day after feeding. Around 4 weeks of age she began to have more “emesis” up to 8-9 times/day that was now forceful and the infant was hungry after these episodes. She had been seen in various urgent care centers, had her formula changed 3 times, and was started on Ranitidine without resolution. Her parents had noted that she appeared to be more tired and was moving less and sleeping more recently. The social history found the parents were married with a 3 year old child who was well. The family history was negative.

The pertinent physical exam showed normal vital signs, height of 53 cm (5% for age), weight of 3.2 kg (50% for 1 month old) and head circumference of 37.5% (25% for age). She looked malnourished and was easily aroused. During feeding she was noted to have a large peristaltic wave and a palpable mass in the epigastric area. The laboratory evaluation showed a sodium of 120 mEq/L, potassium of 2.2 mEq/L, chloride of 70 mEq/L, carbon dioxide of 49 mmol/L, BUN of 12 mg/dL and creatinine of 0.5 mg/dL. She had a normal complete blood count. The radiologic evaluation showed a very large gastric bubble on plain abdominal radiograph, and pyloric stenosis on the ultrasound with a width of 5-6 mm and length of 3.2 cm The diagnosis of pyloric stenosis was made. The patient had her severe dehydration and hypochloremic metabolic alkalosis treated with multiple fluid boluses and additional electrolytes. A nasogastric tube was placed for decompression. After fluid and electrolyte resuscitation, she was taken to the operating room for a pyloromyotomy. She had no complications before or after surgery.

Case Image
Figure 98 – AP radiograph of the abdomen demonstrates a distended stomach with a peristaltic wave within it, the “caterpillar sign.”
Case Image
Figure 99 – Sagittal (left) and transverse (right) ultrasound images of the pylorus show the pylorus muscle to be elongated in length (3.2 cm) and thickened in diameter (0.5 cm), the classic findings of pyloric stenosis.
Discussion
Hypertrophic pyloric stenosis is the hypertrophying of the pylorus muscle with subsequent stenosis of the pyloric channel. It usually presents in the 3-12th week of life as forceful or projectile non-bilious emesis. It occurs ~ 2-5 patients/1000 live births, more often in males than females (4;1) and most often in first-born males (30%). The infant often appears hungry after feeding.. It can cause failure to gain normal weight, weight loss, and metabolic abnormalities (classically a hypochloremic, hypokalemia metabolic alkalosis). Classically a small abdominal mass about the size of an olive can be palpated at the mid- to right upper quadrant just lateral to the rectus abdominus muscle. On ultrasound examination, a pyloric muscle thickness of > 4 mm is considered diagnostic. The length of the muscle is variable from 14-20 mm, and pyloric diameter may be between 10-14 mm.

Weight loss is a non-specific symptom that can have multiple easy explanations (e.g. inaccurate measurement, acute dehydration, etc. ), but many others are more insidious (i.e. anorexia, thyroid disease) or ominous (e.g. oncological disease, renal failure, etc.) The symptom of true weight loss is more likely to be caused by organic disease than the symptom of weight gain. It needs a detailed history, physical exam and considered laboratory approach to its evaluation. For young children, failure to thrive or lack of normal physiological growth and development has many overlapping etiologies.

Learning Point

The differential diagnosis of weight loss includes:

  • Inaccurate measurement or recording
  • Different scales
  • Normal for situation
    • Newborn period
    • Weight management
    • Medical treatment e.g. edema
  • Improper feeding techniques or beliefs
  • Inadequate food
  • Chronic disease
  • Endocrine disease
    • Panhypopituitarism
    • Thyrotoxicosis
  • Infectious disease
    • Fungus
    • Endocarditis, bacterial
    • HIV
    • Parasites
    • Tuberculosis
  • Nutritional
  • Psychiatric disease
    • Anorexia nervosa
    • Conversion disorder
    • Depression
    • Schizophrenia
  • Gastrointestinal disease
    • Diarrhea, chronic
    • Emesis
    • Crohn’s disease
    • Pancreatitis, chronic
    • Ulcerative colitis
  • Congenital heart disease
  • Diabetes
  • Cystic fibrosis
  • Oncological disease
  • Renal disease
  • Medication side effects
    • Stimulants
  • Medical abuse
    • Laxative

    Questions for Further Discussion
    1. What history questions should be asked when evaluating for weight loss?
    2. What is a healthy weight loss rate for someone with obesity?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Stomach Disorders

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003.

    Bacon GE, Spencer ML, Hopwood NJ, Kelch RP. A Practical Approach to Peditric Endocrinology. Year Book Medical Publishers, Chicago, IL. 3rd Edit. 1990.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Causes Halitosis?

    Patient Presentation
    A 10-year-old female came to clinic with ear and facial pain for 2 days. She had seasonal allergic rhinitis symptoms beginning 5 days previously. One day ago she developed left ear pain and general pain near her eyes. Her mother also said, “Her breath stinks like a dragon.” Initially her nasal secretions were copious amounts of clear discharge, but they had changed the day before to being thick, and yellow-green. The past medical history showed several years of seasonal allergic rhinitis. The review of systems revealed no fever, but increased tearing.

    The pertinent physical exam showed a school age girl in minor pain with red eyes. HEENT examination showed her eyes with palpebral redness. Her nose had thick yellow-green secretions with edematous membranes, There was positive tenderness of the maxillary sinuses, nasal secretions in the posterior pharynx and strong fetid breath. Her left ear was erythematous, bulging with distorted landmarks. Her right eye had clear fluid with air bubbles. Lungs were normal. The diagnosis of seasonal allergic rhinitis with secondary infection of the left ear and probable maxillary sinusitis was made. The patient was recommended to use her antihistamine more regularly, use oxymetazoline for 2-3 days to decrease the swelling in her nose and begin Amoxicillin for 10 days. She was to restart her nasal steroid medication after 7 days assuming improved symptoms. The family was to call if her symptoms worsened or persisted.

    Discussion
    Halitosis or bad breath can be caused by a number of problems. The most common reason is retained food, cellular debris (epithelial cells) and bacteria (usually anaerobic) combining to cause problems in the mouth. These problems combined with decreased saliva (dehydration, mouth breathing, salivary gland disease, diabetes, chemotherapy, medications, etc.) and often poor dental hygiene are some of the most common reasons for halitosis. Other reasons can also include increased protein relative to carbohydrate in diet and the oral pH is more alkaline. The back of the tongue is the most common place for retained food and cellular debris in the mouth, but other head and neck structures also can be involved such as the tonsils, nose and sinus.

    Methods to improve halitosis includes hygiene and increasing saliva production with frequent brushing and flossing of teeth, rinsing the mouth with water, and chewing sugar-free gum. Mouth rinses usually are not recommended for children. Avoidance of xerostomia, medications and certain foods can also help. Treatment of primary or secondary bacterial disease and other medical conditions is also important.

    Learning Point
    The differential diagnosis of halitosis includes:

    • Mouth
      • Cavities and dental abscess
      • Dental appliances – teeth retainers, dentures
      • Gum disease – Necrotizing gingivitis (Vincent’s disease or Trench mouth)
      • Mouth breathing
      • Mucositis
      • Plaque
      • Diphtheria
      • Oral candidiasis
      • Streptococcal pharyngitis
    • Nose
      • Atrophic rhinitis
      • Rhinorrhea
      • Infection
      • Foreign body
    • Sinus
      • Infection
    • GI tract
      • Bowel obstruction or prolonged emesis
      • Gastroesophageal reflux disease – stomach acid
      • Liver failure
    • Renal disease
      • Kidney failure
    • Pulmonary disease
      • Lung abscess
      • Bronchiectesis
    • Drugs
      • Alcohol
      • Inhaled anesthetics
      • Bismuth
      • Iodides
      • Paraldehyde
      • Tobacco
      • Vitamin supplements
    • Medications that cause xerostomia such as antihistamines
    • Medications that cause fungus such as chemotherapy, corticosteroids
    • Food (often because of the oil in the food) is absorbed and then emitted through the lungs)
      • Brassicas – cabbage, brussel sprouts
      • Cheese
      • Coffee/tea
      • Garlic
      • Onions
      • Orange juice
      • Spices
    • Other
      • Cancer – oral, esophageal, gastric
      • Diabetes
      • Head and neck structural disorders, ex. cleft palate which may allow ideal environments for bacteria to multiply without being disturbed
      • Menstruation (associated with transient gingivitis)
      • Psychological – pseudohalitosis or halitophobia

    Halitosis by smell

    • Ammonia – kidney failure
    • Foul, putrid, sulfur – infections and/or debris, hepatic failure
    • Fecal – Bowel obstruction or prolonged emesis
    • Sweet – oral candidiasis, diabetes

    Questions for Further Discussion
    1. What other suggestions for eliminating halitosis do you have?
    2. What are indications for referral to a dentist?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Dental Health and Mouth Disorders.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:170.

    Halitosis. FamilyDoctor.org.
    Available from the Internet at http://familydoctor.org/familydoctor/en/diseases-conditions/halitosis.printerview.all.html (rev. 9/10, cited 4/18/2012).

    MedlinePlus. Bad Breath. National Library of Medicine
    Available from the Internet at http://www.nlm.nih.gov/medlineplus/ency/article/003058.htm (rev. 3/21/2012, cited 4/18/12).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Can Parents Do To Help Their Teens Be Responsible?

    Patient Presentation
    A 13-year-old male came to clinic for wart treatment. When the physician entered the room, the mother and teen were both upset, as apparently the mother had just found out that the teen had lied and setup a social media account online. The physician diffused the situation by talking with the family about overall family communication. The pertinent physical exam showed a healthy teen with normal growth parameters. Two plantar warts 3-5 mm in size were found on the right great toe. The diagnosis of plantar warts was confirmed and while treating the wart the physician emphasized the priviledge the teen had of using a cellphone and Internet, but that there were responsibilities too, especially that the parent could trust the teen. The teen reluctantly agreed that he had broken the social media rule and that the consequence of not using the cellphone and Internet for a week was appropriate. In the meantime, the teen and mother agreed to set up written rules about using the cellphone and Internet.

    Discussion
    Social networking is an extension of normal healthy adolescent development and their off line lives. “…[S]ocial networking sites allow teenagers to explore their identities, make new friends and continue to develop long-standing relationships, explore their sexuality, voice their opinions, and be creative.”

    According to the Pew Internet and American Life Project:
    Online teens (44%) admit to lying about their age at some point to gain access to a website or sign up for an online account, with younger teens more likely to do so than older ones (49% for 12-13 year olds versus 30% for 17 year olds), and teens that use social networking sites also more likely than non-users (49% vs 26%) to do so.

    Online teens (30%) have shared passwords with a friend with online girls more likely than online boys ( 38% v 23%) and older teens more likely than younger teens to share passwords (36% for 14+ years vs. 17% for < 14 years).

    Teens who have set their social networking profiles to private so that only friends can see content is 62% and an additional 19% have set their profile so that it is semi-private (i.e. friends of friends or networks of individuals). At least half of teens (55%) have chosen to not post some type of content because of their concerns that it may reflect on them poorly in the future. Teens that use social networking sites are more likely to withhold content than teens that do not use social networking sites (60% vs. 30%).

    Two percent of teens have sent a sexually suggestive picture or video (sexting) to another person, but 16% have received a similar picture or video.

    Some potential risks of social media use include:

    • Harassment (most common) and cyberbullying
    • Sexting
    • Using inaccurate health information
    • Psychological problems including depression, anxiety, suicide, and Internet addiction. Depression includes possible “Facebook depression” or depression as the result of using Facebook a great deal of time and not measuring up as compared to peers (i.e. not as many friends or status updates)
    • Security risks
      • Stalking or grooming (establishing an emotional connection with a child for purposes of sex or other exploitation)
      • Identity theft
      • Monetary scams
    • Social/Legal action – school suspensions, arrests

    Learning Point
    Parents and teenagers need to continue to talk and monitor the everchanging Internet environment so teens can learn to use social media and other technologies responsibly.

    Parents should:

    • Decide when their teen has the knowledge, attitude and judgment to be responsible enough to be given the privilege of using the computer/cellphone and can understand and follow though with this responsibility.
    • Set clear rules about when, where and how their teen can use a computer/cellphone
      • Computers/cellphone should be used in public spaces such as the kitchen
      • Parent should emphasize what teens are allowed to do – text, chat, post pictures, open new accounts, change passwords etc.
      • Limit friends to someone the teen has actually seen and knows well. Someone that the teen would invite to their home or introduce to their parents
      • Don’t post identifying information online – address, phone, hometown, school, social security number – anything that can help someone else to identify the teen
      • Never meet anyone face to face that they have met online
      • Don’t give out passwords to anyone but parents – not even friends
    • Go online and help the teen set up their accounts and set privacy settings.
    • Monitor online activities just like they would any other activity
      • Ask teens who are their friends, who are they talking to, what are they doing
      • Ask to see the teen’s profile – give them time to remove something that shouldn’t be there but if others can already see it, then it is not invading privacy
      • Be one of their teen’s friends to be able to monitor what their teen is doing. If the teen doesn’t want to be a friend, then this is a red flag.
    • Talk with their teens. Tell and remind them often to:
      • Talk with the parent if anything makes them feel uncomfortable, strange, weird, embarrassed, hurts or scares them
      • If the teen sees any harassment or cyberbullying
      • If the teen sees any sexting
        • This can result in legal action including felony and misdemeanor arrest for pornography distribution and privacy issues. It can also include school/team suspension or dismissal.
      • Don’t believe everything that the teen reads – teach them to be appropriately skeptical, and ask them if they can verify it
      • Not write or post anything online that the teen wouldn’t be comfortable giving to a parent, coach or sending with their college, scholarship or job application
        • Everything that is posted will be there forever and anyone can access everything.
        • Be particularly careful about anything that could be construed as substance abuse (i.e. alcohol, tobacco or drugs), engaging in behavior that others may judge differently (i.e. sexual material) or even potentially extreme political or social views. Others may judge the information differently.
      • Be a good citizen online and that parents will not act in a punitive way unless it is warranted by not following the agreed rules and the teen is not behaving in a way that shows they are responsible enough for the privilege.
    • Parents should also model their own good citizenship

    Questions for Further Discussion
    1. What are potential legal penalties for Internet harassment and/or cyberbullying?
    2. What are the major regulations in the Children’s Online Privacy Protection Act?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Warts and Internet Safety.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Ybarra ML, Mitchell KJ, Finkelhor D, Wolak J. Internet prevention messages: targeting the right online behaviors. Arch Pediatr Adolesc Med. 2007 Feb;161(2):138-45.

    Mitchell KJ, Ybarra M. Social networking sites: finding a balance between their risks and benefits. Arch Pediatr Adolesc Med. 2009 Jan;163(1):87-9.

    O’Keeffe GS, Clarke-Pearson K; Council on Communications and Media. The impact of social media on children, adolescents, and families. Pediatrics. 2011 Apr;127(4):800-4.

    Lenhart A, Madden M, Smith A, Purcell K, Zickuhr K, and Rainie L. Teens, kindness and cruelty on social network sites. Pew Internet and American Life. 11/9/2011
    Available from the Internet at: http://pewinternet.org/Reports/2011/Teens-and-social-media.aspx

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital