Re-referral

Davina is once again seen in the neonatal follow up clinic. You find out from the parents why she has been brought back.

Her parents tell you that she is now 11 months old. She was doing really well in every respect until the last 3 months or so. She was developing well, had learnt to use her hands and was sitting up confidently. She had learnt to distinguish between her close relatives and those she knew and strangers. She was also a very happy baby.

About 3 months ago, things began to change. It was difficult to notice at first, but perhaps the first change was that she was no longer as happy as she had been – a bit more irritable. The next indication was that her weight gain was less than it had been before – she was growing at a steady 200-250 g every week at one stage, but this was some time ago. So her parents decided to come back to see you in the neonatal clinic as you had been so sensible before – pinpointing a problem with feeding and avoiding unhelpful tests.

You decide to ask some more questions about her feeding and gastrointestinal system.

She is now also eating solid food, and has been from 6 months of age. This is mostly family food, biscuits, cereal and finger food like breadsticks. She is drinking a lot less breast milk now perhaps because she is full with solid food.

She does not vomit up any food except when ill with a virus and a fever. At the other end, her stool is looser than it had been, and quite bad smelling too. Her parents put this down to the solid food in her diet.

When you examine her, she has obvious grown in the last months, but again looks quite thin. Her abdomen is not tender, but is a little distended.

She is again measured - Weight 7.9 Kg, length 73 cm, head circumference 45.5 cm.

Her mother now produces her baby growth records with a number of other measurements in.

After some persuasion, the parents agree to some blood being taken for basic blood tests – a full blood count, liver function, renal function and electrolytes. You agree in addition to check an antibody panel and the thyroid profile.

After a week the parents bring Davina back. They describe the blood test, which was quite traumatic for their baby as there was difficulty getting enough blood for the tests.

The results are shown below, with adult normal ranges:

Davina’s parents ask you to explain what the tests mean and what you intend to do next.

What would you like to do now?