CASE. Maggie and Lily are 11 month-old twins who are brought by their parents to the Developmental-Behavioral Pediatric Clinic for a life-long history of feeding difficulties.
The twins are this couple's first children. Their mother is tearful as she recounts a stressful pregnancy complicated by pre-term labor beginning at 24 weeks gestation with strict bed rest for the remainder of the pregnancy. The twins were delivered at 35 weeks gestation by Caesarian Section. Lily weighed 5 lbs 11 oz; Maggie was small-for-gestational age with a birth weight of 3 lbs 13 oz. Maggie required oxygen with nasal prongs for only a few hours after birth. She remained in the Neonatal Intensive Care Unit (NICU) with initial nasogastric tube feeding; she was advanced to bottle feeding prior to discharge.
Both Maggie and Lily were slow to initiate and sustain formula feeding. They required over 1 hour to consume 2 ounces of formula and “tire easily”. At 1 month of age, Maggie resisted feedings by crying and arching her back. By 5 months of age, both children cried at the sight of the bottle and tried to push it away. However, they never lost weight. Maggie was treated with intermittent naso-gastric tube feeding at 5–6 months of age in order to gain adequate weight. At 11 months of age, both girls continued to resist feeding, but their mother was able to “get in” 24 ounces each day of a 31-calorie/ounce formula “with a lot of work”. Dad observed that his wife's entire day revolved around getting the twins to eat and that became a significant stress for her as well as on their relationship.
The children had a gastroenterology evaluation including an upper gastrointestinal series, pH probe and gastro-duodenal endoscopy with biopsies. All studies were normal. Trials of omeprazole, metoclopramide and thickened feeds did not improve their feeding problem. They are currently not on any medications. They have not had a history of vomiting, diarrhea, or diaphoresis with feeds, and they have experienced only 1 mild upper respiratory infection. One or two soft bowel movements occur each day. Developmentally, they are on track for their age. The parents report that they can pull up to a stand and cruise, use a pincer grasps, and speak “mama” discriminately.
A review of their growth charts reveal that their weight is consistently between the 10–25% percentiles; weight is currently at the 25% percentile. Head circumference and height are between the 25–50% percentiles.
Daniel B. Kessler, MD, Director, Developmental and Behavioral Pediatrics, University of Arizona, College of Medicine, Children's Health Center of St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
Erin L. Fortune, MD, Resident in Pediatrics, University of California, San Diego, California.
Ellen G. Werner, MFT, Clinic Coordinator, Developmental-Behavioral Pediatrics Clinic, Children's Hospital, San Diego, California.
Martin T. Stein, MD, University of California, San Diego Children's Hospital, San Diego, California.