Failure to thrive in a child—what’s the cause?

August 06, 2018

Figure 1 Quiz of the Week

A three-year-old African American boy is brought to his new pediatrician over concerns of poor growth, fatigue, and irritability. On examination, he has a large head and generalized muscular hypotonia. His left wrist demonstrates the findings seen here. 

What next step is most appropriate?

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Image credit: @Danflanders.


Answer: Nutrition counseling

This patient’s clinical presentation is consistent with a diagnosis of vitamin D deficiency rickets. The condition is most commonly associated with maternal prenatal vitamin D deficiency, a diet during infancy that is deficient in vitamin D, minimal sun exposure, or intestinal malabsorption of vitamin D. The diagnosis can be confirmed with imaging and blood work. X-rays typically demonstrate diffuse osteomalacia and metaphyseal widening/cupping of the wrists, ankles, or knees. Laboratory findings include low 25-hydroxy vitamin D, low ionized calcium, low phosphorus, and elevated alkaline phosphatase. While being treated with daily doses of vitamin D (up to 10,000 IU/d) over 2-3 months, patients should also receive nutrition counseling.

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