Page 11 of 11
PE2.1-3 | Growth Problems — PBL Case
CLINICAL SETTING
You are a final-year MBBS student on a paediatrics posting at a district hospital in rural Telangana. The outpatient clinic is busy on a Monday morning. The next patient is Ritu, a 3-year-old girl, brought by her grandmother. The mother works as a daily-wage agricultural labourer and could not attend. The grandmother is visibly anxious: 'Doctor, the Anganwadi worker said my granddaughter is 'red' on the MUAC tape and sent us here. She looks small but she eats whatever we give her at home.'
Trigger 1: The Initial Encounter — History and First Measurements
You examine Ritu. She weighs 8.2 kg and her height is 80 cm. Her MUAC is 11.2 cm. On the WHO growth chart, her weight-for-height Z-score is −3.2 and height-for-age Z-score is −3.1. She has no bilateral pedal oedema. She is alert and interactive but visibly wasted — ribs visible, subcutaneous fat reduced. The grandmother reports Ritu eats mainly rice and dal twice a day with small amounts of milk. She was never breastfed (mother returned to work within a week of delivery). There are no episodes of diarrhoea currently, though she had three bouts of acute diarrhoea in the last six months. She has not been hospitalised before. Immunisation card shows incomplete vaccination — only BCG and first doses of pentavalent and OPV received.
DISCUSSION POINTS
- Based on the anthropometric data (weight 8.2 kg, height 80 cm, WHZ −3.2, MUAC 11.2 cm, no bilateral oedema), how would you classify Ritu's nutritional status using WHO/IAP criteria? Which single measurement alone would qualify her for SAM?
- What additional history would you prioritise to distinguish non-organic (inadequate intake) from organic (malabsorption, chronic infection) causes of her poor growth? What psychosocial factors are already evident?
Click to reveal Trigger 2: Examination and Initial Investigation Results (discuss previous trigger first!)
Trigger 2: Examination and Initial Investigation Results
Physical examination: Ritu is afebrile (temperature 36.8°C), heart rate 110/min, respiratory rate 24/min. No respiratory distress, no oedema. Skin shows grade 2 loose skin folds (baggy pants sign). Hepatomegaly is not present. No pallor, no lymphadenopathy. Capillary blood glucose is 3.8 mmol/L. You complete a 24-hour dietary recall with the grandmother: two small meals per day (rice + lentil soup), total estimated caloric intake approximately 600 kcal/day (estimated requirement for age ≈ 1000–1100 kcal/day). There is no diarrhoea currently. Stool is normal consistency. The family lives in a single-room house with six members; the father is a migrant labourer, largely absent. The family was unaware of Anganwadi supplementary nutrition services.
DISCUSSION POINTS
- The dietary recall shows approximately 600 kcal/day against an estimated requirement of 1000–1100 kcal/day, and there is no current diarrhoea or hepatomegaly. How does this information help you classify the cause of Ritu's SAM as organic or non-organic? What is the most likely primary mechanism?
- Ritu's blood glucose is 3.8 mmol/L. Is immediate glucose treatment indicated? What is the SAM hypoglycaemia threshold, and what does the WHO protocol recommend as step 1?
- What investigations, if any, would you order at this stage, and in what priority order?
Click to reveal Trigger 3: Management Decision and Family Counselling (discuss previous trigger first!)
Trigger 3: Management Decision and Family Counselling
The medical officer reviews Ritu. She has no acute complications (no hypoglycaemia, no hypothermia, no severe dehydration, no high fever, respiratory rate is normal). She is alert and able to feed orally. The hospital has F-75 therapeutic milk and is enrolled in the Community-based Management of Acute Malnutrition (CMAM) programme. The team decides she meets criteria for SAM but is classified as 'uncomplicated SAM' — eligible for outpatient therapeutic care with RUTF (ready-to-use therapeutic food) under the CMAM protocol, with close follow-up. The grandmother is worried and asks: 'Will my granddaughter be normal? Will she catch up? What should I feed her at home?'
DISCUSSION POINTS
- What is the WHO/IAP criteria that distinguishes complicated SAM (requiring inpatient management) from uncomplicated SAM (eligible for outpatient CMAM)? Does Ritu qualify for outpatient management?
- How would you counsel the grandmother? Include: (a) what the diagnosis means in lay terms, (b) specific home feeding instructions including energy-dense foods available locally, (c) responsive feeding guidance (avoid force-feeding), (d) red flag signs requiring immediate return to hospital, (e) the follow-up plan.
- What community-level interventions and referrals would you initiate? (Anganwadi, ICDS, immunisation catch-up, social support)
Click to reveal Trigger 4: Six Months Later — A New Growth Problem (discuss previous trigger first!)
Trigger 4: Six Months Later — A New Growth Problem
Six months after Ritu's treatment, she has achieved catch-up growth (MUAC now 13.0 cm, WHZ −1.8 SD). She is now 3.5 years old. Her grandmother brings her again, but with a different concern: 'The school teacher says Ritu is much shorter than all her classmates. The boy next door is the same age but almost a head taller. Is something wrong with her height?' You plot Ritu's height: height-for-age Z-score is −2.8 SD. Her parents' heights are: mother 148 cm, father 162 cm (reported). Mid-parental height for a girl ≈ (162 + 148 − 13)/2 = 148.5 cm (target range 143.5–153.5 cm). Her bone age X-ray shows a bone age of 3.0 years (chronological age 3.5 years — only 6 months delayed). Growth velocity over the past 6 months is 4.5 cm/6 months (= 9 cm/year — appropriate for age ≥5 cm/year). Thyroid function is normal. IGF-1 is normal for age.
DISCUSSION POINTS
- How would you classify Ritu's short stature at this point? Consider: (a) HAZ −2.8 SD, (b) bone age only 6 months delayed, (c) normal growth velocity (9 cm/year), (d) mid-parental height target range 143.5–153.5 cm — her predicted adult height if current velocity continues. What is the most likely explanation?
- How would you counsel the grandmother and explain the distinction between Ritu's current short stature and pathological short stature requiring intervention? What monitoring plan would you propose?
- At what HAZ or with what additional findings would you escalate to GH stimulation testing, bone age re-evaluation, or karyotyping? Discuss the decision thresholds.
Group Task Assignments
Group 1: Collaborative Task
Group 2: Collaborative Task
Group 3: Collaborative Task
Learning Issues
Research these questions and bring your findings to the discussion.
- [PE2.1] What are the WHO/IAP criteria for diagnosing severe acute malnutrition (SAM), and how do you distinguish complicated from uncomplicated SAM for management pathway allocation?
- [PE2.1] What are the 10 steps of the WHO SAM inpatient management protocol, and in which order must life-threatening conditions (hypoglycaemia, hypothermia, dehydration, infection) be addressed before nutritional rehabilitation?
- [PE2.1] What dietary history, physical examination findings, and initial investigations distinguish organic from non-organic failure to thrive?
- [PE2.2] What are the key elements of effective counselling for a family managing a child with failure to thrive, and how do responsive feeding principles differ from force-feeding?
- [PE2.2] How do social determinants (poverty, caregiver availability, ICDS services) influence FTT counselling and what community-level interventions should be initiated alongside clinical management?
- [PE2.3] How is short stature defined, and what is the stepwise approach to investigating it — distinguishing familial short stature, constitutional delay, endocrine causes (GH deficiency, hypothyroidism), systemic disease, and chromosomal disorders?
- [PE2.3] What is the role of bone age (X-ray of left wrist), IGF-1, and height velocity in the diagnostic workup of short stature, and how do these findings guide the decision to proceed to GH stimulation testing?