Several elements in the history present as possible causes of Ebony's failure to thrive (FTT). In a multivariate analysis, FTT between birth to 8 weeks of age is associated with maternal prenatal factors (such as a lack of transportation, socioeconomic class) and infant postnatal factors (weak sucking). While Ebony has had no significant physical symptoms, the birth weight of 4.9 kg equals macrosomia which can sometime be associated with weak sucking and slow feeding, which in turn can result in smaller quantities being expressed per feeding session and an increase in maternal fatigue. It would be difficult to continue to breast feed exclusively while working full time, without personal transportation and with another child to care for, and Tina should be congratulated for her tenacity in attempting to continue to breastfeed. While working full time, Tina has still had difficulty affording food at times, and it may be that her caloric intake is not enough to sustain adequate breastfeeding for Ebony. Additionally, at six months it would be ideal to offer small solid feedings at six months, and it does not appear from the history that Tina has been able to start this yet.
             Several medical conditions could be contributing to Ebony's poor weight gain. The mere fact that there is not enough money could mean that Tina has continued to rely solely on breastfeeding at a time when Ebony needs to progress to more varied foods. Additionally, Ebony must be evaluated for any mechanical feeding difficulty, such as reflux, oromotor dysfunction, or central nervous system abnormality. Conditions which may contribute to Ebony's FTT which are not readily evident on physical examination include celiac disease, hyperthyroidism, chronic infection such as HIV, or metabolic disorders such as amino acid storage disorders. It would be helpful to obtain information on Ebony's eating and stooling patterns, whether or not she has ...