Case Presentation:

RB was a 6 week old full term infant who presented with lack of expected weight gain. Birth weight was 2.6 kg (3%) and her admit weight was 2.47 kg (3 Standard deviations below the mean). Her OFC and length both dropped from the fiftieth percentile to the third. She was a 39 week EGA infant born by C–section for fetal decelerations to a G3P1 mom (two spontaneous abortions). Mom had some difficulty with breastfeeding, but reported a sense of engorgement and milk let down. Mom breastfed every 3–4 hours followed by supplementation with 1–2 oz of expressed breast milk or Similac since 1 week old. The patient had non–bloody, non–bilious, non–projectile emesis since birth, but it became more prominent in the week prior to admission. There was no coughing or choking with feeds. She had no delayed passage of meconium and had normal stools 1–2 times a day. She had no lethargy, fever, difficulty breathing, cough or rhinorrhea. On physical exam, she was very thin with prominent bony structures and minimal subcutaneous fat. There were no facial dysmorphisms or cleft palate. Cardiac and abdominal exams were normal. She had normal tone and activity level. There was a slight head lag. Laboratory evaluation was unremarkable, including a newborn screen, complete blood count, complete metabolic profile, and urinalysis. Calorie count and weight checks resulted in a modest increase in weight to 2.53 kg over 2 days with 135 kcal/kg/day intake. Observation of feeds confirmed good suck and swallow mechanics. Direct observation of voluminous emesis prompted evaluation with an upper GI study. The UGI revealed a large partially obstructing sliding hiatal hernia. After 4 days of continued failed weight gain, pediatric surgery performed a hiatal hernia repair with Nissan fundoplication and G–button placement on hospital day #7. The G–button was intended to be temporary and aide in the prevention of recurrence of the hernia. Post–operatively, she tolerated g–button feeds and ultimately oral feeds. She was discharged on hospital day #16. Following discharge, she has continued to thrive with no emesis. By 6 months old, she returned to the third percentile for weight, thirty–fifth for length, and twenty–fifth for OFC.

Discussion:

The differential of lack of expected weight gain in infancy is broad. The evaluation should be tailored to the history and exam. While vomiting in infants is often appropriately minimized by healthcare providers, this case illustrates the importance of direct observation of feeds and emesis when possible to determine the severity. Although a rare diagnosis in infants with poor weight gain, hiatal hernias should be considered when emesis is prominent.

Conclusions:

The purpose of reporting this case is to illustrate a rare cause of lack of expected weight gain in infancy and to highlight the importance to pediatric hospitalists of direct observation of feeds and emesis.

Figure 1Upper GI showing large contrast collection above the diaphragm representing the sliding hiatal hernia.

Figure 2Weight–for–age WHO growth chart before and after hiatal hernia repair.