Eczema and poor growth (medical neglect)

Question 1

You are referred a 12-month-old with poor growth. On review her weight, length, and head circumference are below the 3rd centile. She reportedly has severe ezcema with her parents having pursued alternative medicine treatments up until this time.

Answer 1

Impression:
Most concerning features of this stem are the child apparent poor growth which may represent a failure to thrive. Notably, this may be a result of severe eczema that has been poorly treated leading to the poor growth. I am also concerned about potential medical neglect in this case given the pursuit of alternative medicines.

There are a number of potential causes of failure to thrive which should be considered. Provisionally I think this is related to severe eczema, but could also be due to;
- Other chronic illness (Cardiac, renal)
- Inadequate nutrition
- psychosocial factors
- breastfeeding difficulties (cleft palate)

Get FTT in Eczema, Vit D and Zinc

Goals:
- identify whether there is a failure to thrive/ not meeting expected growth
- initiate appropriate treatments for growth and to acute and ongoing management of the patient’s eczema
- Family education

Question 2

Eczema and poor growth - History

Answer 2

History
- PC: eczema: when started, flares, treatments used to date, effectiveness, any skin infections.
Poor growth: assess historical growth charts, confirm low gentile anthropometric measurements, food behaviour, nutritional efforts
- consequences of severe eczema: feeding, irritability, developmental milestones, distribution of rash, triggers?
- REDFLAGS: regression of development
- Paediatric Hx (immunisations, milestones, etc), antenatal Hx and family Hx of delay, poor growth
- other medical conditions: (asthma, etc - atopic)
- Obstetric Hx
- medications, allergies
- ask about parental development, familial stature
- Psychosocial: family assessment, home environment

Question 3

Eczema and poor growth - Examination

Answer 3

Examination:
- General observation: small, irritability, skin rashes location and severity, unwell vs well?
- Plot height, weight, and HC on chart - check for crossing of lines (Evidence of regression) or if always below 3rd gentile
- skin: paeds usually get eczema in folds (neck, arms, knees), any signs of infection
- Hydration and fluid status:
- observe in play for milestones (motor, social, language)
- Muscle-bulk,

Question 4

Eczema and poor growth - Investigations

Answer 4

Investigations
No investigations may be indicated for an otherwise healthy and well-developing child according to growth potential.

Severe eczema is a clinical diagnosis and no further investigations are require.

Investigations for poor growth:
- Bedside: UA
- Bloods: FBC, UEC, LFT, folate/B12, iron studies, vitamins panel, TFTs, coeliac serology, CMP
- Imaging: nil initial
- Vit D and Zinc - (common in children with atopic illness).

Question 5

Eczema and poor growth - Management

Answer 5

Management
Depends on what the key underlining issue for the Childs poor growth is. Key principles to management include
- MDT for ensuring optimal growth
- referral to paediatrician if any concerns about underlying systemic illnesses or significant delay/poor growth
- consider legal aspects of medical neglect in setting of alternative treatments pursued for eczema, particularly if they have contributed to poor growth
o mandatory reporting to DCJ via scan protocol
o SCAN protocol in combination with DCJ and senior clinician help
- parent education in non-judgemental tone, issues associated with severe eczema and growth potential
- regular follow-up and weights

For eczema
- no cure, just optimal daily skin care management:
- moisturiser use, eczema baths, daily bathing, trigger avoidance, topical steroids if severe, oral antimicrobials if signs of infection, bleach baths
- should continue skin-care routine daily even if skin is not bad at the time
- admission for;
o wet dressings
o bathing

Consider for inpatient treatment if significant poor growth/malnourishment is identified.