Basics
Description
Documented decrease in weight from a previous measurement. Outside of newborn period (weight loss in the first 2 weeks is common), acute illnesses resulting in fluid losses, and obese children voluntarily on a designed weight reduction program, weight loss is an unusual and worrisome symptom, regardless of the percentage decline. ‚
Diagnosis
History
Determine that weight loss is real and not due to scale error, different scales, different technique (e.g., clothed vs. unclothed). ‚
- Question: Child 's diet?
- Significance: A prospective 3-day dietary record can be useful for demonstrating insufficient caloric intake.
- Question: Age?
- Significance: The patient 's age can very much indicate the most likely causes of weight loss to which questions about the history can be directed.
- Patient <2 weeks old: physiologic weight loss, underfeeding, inappropriate feeding, inborn error of metabolism, congenital heart disease, gastroesophageal reflux
- Patient <4 months old: malnutrition, improper formula preparation, cystic fibrosis, gastroesophageal reflux, pyloric stenosis, congenital heart disease, congenital adrenal hyperplasia, inborn error of metabolism
- Patient 4 months " “8 years old: chronic infection, cystic fibrosis, malabsorption, neglect/abuse, renal disease, liver disease, diabetes mellitus
- Patient >8 years old: eating disorder, chronic infection, neoplasm, renal disease, liver disease, substance abuse, diabetes mellitus, inflammatory bowel disease, collagen vascular disease
- Question: Vomiting, especially projectile?
- Significance: suggestive of intestinal obstruction, gastroesophageal reflux, inborn error of metabolism
- Question: Cramping, bloating, or abnormally greasy, voluminous stools?
- Significance: possible malabsorption
- Question: Tiring during feeding or difficulty feeding due to cough and dyspnea?
- Significance: suggests congestive heart failure in newborn/infant, hypothyroidism
- Question: Altered mental status, seizures, unusual body/fluid odors?
- Significance: possible inborn error of metabolism
- Question: Maternal history of multiple miscarriages, neonatal deaths, or consanguinity?
- Significance: possible inborn error of metabolism
- Question: Foreign travel?
- Significance: possible chronic infection (e.g., tuberculosis, parasitic disease)
- Question: History of severe infections, persistent candidal infections?
- Significance: possible immunodeficiency, congenital or acquired
- Question: Headaches, especially early morning?
- Significance: possible increased intracranial pressure, CNS malignancy
- Question: Increased appetite with weight loss?
- Significance: suggests hyperthyroidism, cystic fibrosis, pheochromocytoma
- Question: Polyuria, polydipsia, and polyphagia?
- Significance: possible new-onset diabetes
- Question: Concomitant delayed puberty?
- Significance: suggests chronic severe weight loss, pituitary abnormalities, anorexia nervosa
- Question: Fear of fatness, preoccupation with food, distorted body image, and/or amenorrhea?
- Significance: possible eating disorder
- Question: Chronic sadness or irritability, insomnia or hypersomnia?
- Significance: possible depression/affective disorder
Physical Exam
- Finding: Hypothermia, bradycardia?
- Significance: suggests anorexia nervosa, hypothyroidism
- Finding: Tachycardia, resting?
- Significance: hyperthyroidism, pheochromocytoma, anemia, acute weight loss
- Finding: Orthostatic changes?
- Significance: significant weight loss, possibly acute
- Finding: Hypotension, resting?
- Significance: Addison disease, anorexia nervosa, significant acute dehydration
- Finding: Visual field abnormalities?
- Significance: suggests possible CNS malignancy
- Finding: Clubbing?
- Significance: suggests chronic cardiac, pulmonary, or intestinal disease
- Finding: Swollen joint?
- Significance: juvenile idiopathic arthritis, inflammatory bowel disease
- Finding: Significant abdominal distension?
- Significance: suggests celiac disease
- Finding: Enlarged liver and/or spleen?
- Significance: suggests malignancy, chronic infection, storage disease, inborn error of metabolism
- Finding: Muscle weakness?
- Significance: connective tissue disorder, electrolyte abnormality, muscular dystrophy
Alert
- Be certain that the weight loss is real. In some studies, up to 25% of weight loss is artifactual, resulting from measurement errors (e.g., excessive movement of scale, dressed vs. undressed patient).
- Newborns with weight loss, especially at the 2-week visit, may manifest passivity and paradoxical lack of interest in feeding, although the reason for their problem is malnourishment due to inadequate intake (often from improper positioning or too infrequent feedings). They may not act "hungry. " ¯ Observation of the feeding technique (by a practitioner with expertise or a lactation consultant for breastfed babies) is vital.
Diagnostic Tests & Interpretation
- Test: CBC for evidence of the following:
- Significance:
- Anemia " ”macrocytic associated with folate/B12 deficiency, microcytic with iron deficiency or chronic infection
- Polycythemia " ”suggestive of chronic pulmonary or cardiac disease
- Neutropenia " ”suggestive of hematologic malignancy, Shwachman syndrome, immunodeficiency
- Lymphopenia " ”suggestive of immunodeficiency
- Eosinophilia " ”suggestive of parasitic disease
- Leukocytosis " ”suggestive of infection
- Lymphoblasts " ”suggestive of leukemia
- Thrombocytosis " ”suggestive of chronic infection, malignancy
- Test: serum electrolytes
- Significance: abnormalities in dehydration, adrenal insufficiency (low sodium, high potassium), renal disease, anorexia nervosa
- Test: BUN, creatinine
- Significance: abnormal in renal disease, dehydration
- Test: erythrocyte sedimentation rate
- Significance: may be elevated in inflammatory bowel disease, chronic infections, rheumatoid diseases
- Test: stool for occult blood and pH, reducing substances (Clinitest)
- Significance:
- Occult blood suggests inflammatory bowel disease.
- Low pH and positive reducing substances suggest malabsorption.
- Test: Urinalysis
- Significance:
- Hematuria and/or proteinuria suggest renal disease.
- Glycosuria suggests diabetes mellitus.
- Very low specific gravity suggests diabetes insipidus, chronic renal failure, hypercalcemia.
- Pyuria suggests UTI.
- pH >6 suggests renal tubular acidosis (type I).
- Test: urine culture
- Significance: Evaluation for UTI
- Test: serum protein levels
- Significance: Very low levels imply impaired liver function, severe chronic weight loss, or protein malabsorption.
- Test: tuberculosis skin test
- Significance: possible chronic infection
- Test: liver function tests
- Significance: evaluation for hepatitis, chronic liver disease
- Other tests: Depending on age and clinical findings, other tests to consider include the following: thyroid function tests (TSH), sweat test, tests for malabsorption (e.g., lactose breath test, stool fat, stool for trypsin), tests for metabolic disease (e.g., plasma ammonia, lactate, serum/urine amino acids, urine organic acids), imaging studies (e.g., CT, MRI, bone scan), immunologic studies.
Differential Diagnosis
- Nutritional
- Malnutrition
- Dieting
- Iron deficiency/zinc deficiency
- Postoperative recovery
- Inability to eat (new orthodontic appliances, loss of teeth, chronic mouth ulcerations)
- Congenital/anatomic
- Congenital heart disease
- Pyloric stenosis
- GI malformation (duodenal atresia, annular pancreas, and volvulus)
- Short bowel syndrome
- Lymphangiectasia
- Superior mesenteric artery syndrome
- Gastroesophageal reflux
- Immunodeficiency disorders
- Hirschsprung disease
- Infectious
- UTI
- Tuberculosis
- Stomatitis
- Osteomyelitis
- HIV
- Hepatitis
- Parasitic disease
- Abscess, intraabdominal
- Gastroenteritis
- Postinfectious malabsorption
- Pericarditis
- Histoplasmosis
- Acute severe febrile illness (pyelonephritis, pneumonia, septic arthritis)
- Tumor
- Diencephalic syndrome
- Leukemia
- Lymphoma
- Pheochromocytoma
- Other neoplasms
- Endocrine
- Diabetes mellitus
- Diabetes insipidus
- Hyperthyroidism
- Adrenal insufficiency
- Congenital adrenal hyperplasia
- Hypopituitarism
- Hypercalcemia
- Genetic/metabolic
- Cystic fibrosis
- Shwachman-Diamond syndrome
- Lactose intolerance
- Renal tubular acidosis
- Chronic renal failure
- Inborn errors of metabolism
- Storage diseases
- Muscular dystrophy
- Lipodystrophy
- Allergic/inflammatory
- Inflammatory bowel disease
- Juvenile idiopathic arthritis
- Systemic lupus erythematosus
- Sarcoidosis
- Pancreatitis
- Hepatitis
- Celiac disease (gluten enteropathy)
- Psychiatric
- Rumination syndrome
- Depression/affective disorders
- Anorexia nervosa/bulimia nervosa
- Toxic, environmental, drugs
- Lead poisoning
- Mercury poisoning
- Vitamin A poisoning
- Chronic methylphenidate, dextroamphetamine, or valproic acid use
- Substance abuse, especially amphetamines and crack cocaine
- Trauma
- Chronic subdural hematomas
- Miscellaneous
- Child abuse
- Chronic illness (e.g., pulmonary disease, renal disease)
- Cerebral palsy
- Factitious (e.g., scale error)
Alert
Emergency care is indicated for the following: ‚
- Significant dehydration
- Abnormal vital signs with orthostasis, decreased urine output, decreased skin turgor, delayed capillary refill (>3 seconds)
- Mandates cardiovascular support (IV hydration) and a more urgent diagnosis (e.g., inborn error of metabolism, obstructive GI disease, congenital adrenal hyperplasia, diabetic ketoacidosis)
- Abnormal mental status or significant lethargy which may be seen in the following:
- Severe dehydration
- Adrenal insufficiency
- Hypoxic states
- Toxic ingestions
- Renal or respiratory failure
- Increased intracranial pressure
- Severe electrolyte abnormalities
- Increasing vomiting in the setting of known weight loss in infants
- High risk for dehydration, hypoglycemia, and electrolyte abnormalities
- Need to evaluate for treatable conditions (e.g., obstructive GI disease, inborn errors of metabolism, congenital adrenal hyperplasia, congenital heart disease) in which a delay is life-threatening
- Severe malnutrition (weight loss >20% of ideal body weight)
- High risk for metabolic derangements, including dysrhythmias secondary to electrolyte abnormalities
- Aggressive evaluation is warranted.
Treatment
Approach to the Patient
- Establish if the weight loss is voluntary or involuntary.
- Determine the acuity or chronicity and severity of weight loss, and the need for hospitalization.
- Attempt to narrow the diagnostic possibilities by history and physical exam, particularly by assessing if the loss might be attributable to diminished intake, diminished absorption, or increased requirements.
- Treatment is then based on the most likely diagnosis following evaluation.
Additional Reading
- Klein-Gitelman ‚ M. An adolescent girl with weight loss and syncope. Pediatr Ann. 2012;41(3):e1 " “e5. ‚ [View Abstract]
- Macdonald ‚ PD, Ross ‚ SRM, Grant ‚ L, et al. Neonatal weight loss in breast and formula fed infants. Arch Dis Child Fetal Neonatal Ed. 2003;88(6):F472 " “F476. ‚ [View Abstract]
- Schechter ‚ M. Weight loss/failure to thrive. Pediatr Rev. 2000;21(7):238 " “239. ‚ [View Abstract]
Codes
ICD09
- 783.21 Loss of weight
- 530.81 Esophageal reflux
- 263.9 Unspecified protein-calorie malnutrition
- 277.9 Unspecified disorder of metabolism
ICD10
- R63.4 Abnormal weight loss
- K21.9 Gastro-esophageal reflux disease without esophagitis
- E46 Unspecified protein-calorie malnutrition
- E88.9 Metabolic disorder, unspecified
SNOMED
- 267024001 abnormal weight loss (finding)
- 235595009 Gastroesophageal reflux disease (disorder)
- 2492009 Nutritional disorder (disorder)
- 86095007 Inborn error of metabolism (disorder)
- 422868009 unexplained weight loss (finding)
- 699205002 Involuntary weight loss (finding)
FAQ
- Q: How common is weight loss in the first 2 weeks of life?
- A: Formula-fed babies may lose up to 7% of birth weight and breastfed newborns up to 10% before regaining their birth weight by 2 weeks of age. An infant who has not regained his or her birth weight by 2 weeks requires evaluation and intervention.
- Q: How important a finding is weight loss?
- A: Involuntary weight loss is a diagnosticexigency " ”a cause must be found or the loss self-resolved. If a diagnosis is not uncovered in the setting of continued weight loss, referral to a pediatric diagnostic center is indicated.