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Failure to Gain Weight


									                                                                            Failure                                          to                  Gain                                     Weight
                                                                                                    By        L.      EMMETT                 HOLT,               JR.,          M.D.*

T          HE             INFANT                     or          young                   child              who              fails              to          In          many                     instances,                       failure                    to           gain                  weight
           gain                weight                     properly                     without                     any           obvious              is      caused                  by          unappreciated                         losses                of          nutrients
disturbance                                of         digestion                         presents                    an           interest-            in        the           excreta.                       One             of         the          first               of         these                 con-
ing            and              a         puzzling                          clinical                 problem.                           Where ditions                          to         come               to        my            attentiomi                           was                  that              of
does   the  food go? We   put    in a normal        quan-      nia!k.!4    steatorrhea.                                                                                                                           An          excess                  of           fat             may                be
tity of a normal   food.    The     excreta     do not    seem lost in the stools,                                                                                                                              although                       the           gross     and                          often
to be in any way abnormal       andyet      gain in weight the          microscopic                                                                                                                               appearance                                  remnains                              quite
is       either                     stationary                              or         minimal.                          Sometimes                    normal.                         I          became                     aware                    of            this                  condition
this           situation                        is        encountered                               after           an        acute                    some
                                                                                                                                                     ill-                years                   ago           imi         Baltimore                          when                       we              were
                                                                                                                                    dis- running       fat balance                                                         studies                  on            normal                        babies

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ness,           sometimes                                  it      follows                     some                chronic
order;               in         still           other                   cases            it        cannot              be    related     fed different     kinds                                                  of fat.3                   Fromn   time                                to time
to any                 antecedent                                 or          precipitating                          disease         and one of our subjects                                                        would                 pick    up an                               infection
is evident                       in very                        early            infancy.                      In        New             York and                     develop                     diarrhea,                        necessitating                    an              inter-
City    we                  encounter                         this   problem      not very                                               infre- ruption                         of        the          study.           We would                             wait              for             this
quently                     among                         immigrants         from    Puerto                                              Rico, to subside,     allowing                                                a few days                             in          addition                         for
whose                diet             and            living              conditions                         have           been           sub- good    measure       before                                                 resuming                         the              study,                     but
standard,                       but it is by                           no        means               confined                    to      this         almost              in variably                         the findings                           of the                   first         period
group.                         We     correct                                 the         diet,               and            rid          these after                  the   infection                          had   to be                         discarded                             because
children         of such       parasites                                                      as      they    may                        have. of an                    unsuspected                             steatorrhea.                        The            water                      and
Yet      often     for    many        months                                                        they    do not                           gain electrolyte                         losses       had                            ceased     and                                   the              stools
weight         and     grow      properly.                                                            Where      does                          thewere      no                 longer       loose,     but                         fat absorption                                         had          not
energy                go?                                                                                                                             yet        returned                        to     normal.                  The                  time   required        for
   The               few experiments                                             of Siwe’                  in which                   bomb            the        assimilation                           of fat             to return                   to normal      varies
calorimetry                               of         excreta                     were              carried                 out           failed greatly                        in         individual                       infants.                          It      mnay                 be          very
to      reveal                  unusually                          large               losses            by        these              routes.         prompt,                       requiring                     only              a         few            days                   may it
Observations                                   by           Levine                   and            others2      last
                                                                                                                  a      for
                                                                                                                           showed a longer      time.          it If is sufficiemitly           de-
somewhat                                greater                      basal     heat                              layed
                                                                                                                in            and     the  fact       is recognized,               we label         the
these    infants                            per                 unit      of body                            not child
                                                                                                         weight,      but    a celiac.        One          of the          mnost     striking        ex-
enough                    to             account                    for    their    failure      to    thrive. amples           of latent       steatorrhea              is the       steatorrhea
It is difficult       to                                         reconcile       these      observations         of the        premature           infant.             The     stools        in these
with     the first  law                                         of thermodynamics.                               infants        appear     normal           evemi though             as munch        as
   There     are, however,                                                    several               possible                explana-                  50         per           cent              of      the           ingested                       fat           is             being                 lost.
tions            of            this             apparent                            paradox,                   and is
                                                                                                                it                 the                Here,              too,  a mnicroscopic                                        study                   of the                      stool             re-
purpose                    of this                   communication                                    to       call        attention                  veals             no abnormality.
to      several                     that              we           have                encountered.                   An          ap-                       A         simple                remedy                   for          steatorrhea                                 is         to        mnake
preciation                          of      their                miature                mnay          help,           in      somne             in-up           for      the          loss            of calories                  by          aim increased                                  caloric
stam:ces                  at         least,                 to         better                 therapy.                                                intake.                        This              can            be          (bIle               perfectly                               well             by
                                                                                                                                                      adding                    carbohydrate                           or           proteimi.                            We         have
      Froti:              the             Department                     of         Pediatrics,                     New               York            shown,              however,                           that       it can                      also         be            done                 in     all
University      College          of Medicine       and     the    Children’s
                                                                                                                                                      the              forms       of                          steatorrhea                                   that                 we                     have
Medical     Service,     Bellevue      Hospital,     New          N
                                                             York,. V.
   * Professor     of Pediatrics,      New    \ork     University     Col-
                                                                                                                                                      studied4m                             by          giving                    additional                           fat.                         Whemi
lege       of        Medicine,                       1)irector Pediatric                            Service,               Behlevue                   imiore            fat          is      added                   the          proportiomm of                    absorbed
Hospital,                  New              York,                N.         V.                                                                        fat         remains                        unchanged.                       More                is          excreted                    in

September-October                                       19571                                                                                           1-LOLT                                                                                                                                     501

the             stool,                 to      be        sure,                 but            more                 is      absorbed,                           andfraction                       cannot                 be           used              and           spills             out              in       the
we            have               found                 no          evidence                            that             unabsorbed                                 faturine.                 Excessive                         nitrogen                     may                 thus                be           lost
is in            any              way                harmful                        or        causes                    losses                   of        other     both            in     the urine                        and the                   stools.
nutrients                             as       has          been                  feared                   by        some.                                                  We         encounter                       occasional                       examples                       of kwashi-
          Are           there                conditions                             in which                        there                  is masked                 orkor                among                 Puerto                  Rican                  children                      who              come
loss            in         the              stools                 of        nutrients                             other                   than              fat? to           New              York.                  We             have             also         been              fortunate                         in
Loss              of         nitrogen                         is        rarely                     obvious                     to              the           eye. being                   able            to          collaborate                             with              Dr.               Federico
But               it        is         well            recognized                                  that             when                    the             diges- Gome                    and           his       group                in        Mexico                City                 in     a study
tive              secretions                              are                impaired                             considerable                   un-                 of        that              condition.                            The             accompanying                                      Table
split                protein                    may                 escape                     digestion.                                   The              most (Table                    I) shows                     one such                       patient       in                     whom                 ni-
familiar                        example                       of this                condition                         is
                                                                                                                    cystic                 fibro-                    trogen                  balance                     studies                       were     carried                          out                at
sis of the                         pancreas                         in which                           we         attempt                         to        over- intervals.                             There                  is       considerable                variation                           in
come                    thRTiit                             by           giving                        more               protein.                            Le- individual                            cases           in        the           extent               of         the           fecal             and
sions                  of the                  pamicreas                        differing        somewhat                                                   from the urinary                             losses,              but         in this patient                               there                 were
cystic                   fibrosis                 have                       been       observed       in                                      states            of
                                                                                                                                                                  substantial                             losses              by         both    routes.                                When                   first
severe                       chronic                          protein                          deficiency                                  known                     studied,
                                                                                                                                                                     as                           immediately                                on              admission,                           only               32

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malignant                                    malmiutrition,                                                                    and                    by              per        cent             of       the    nitrogen         intake                                 was                 being  ab-
various                          other                names.                             That                     serious                      fecal                  sorbed,
                                                                                                                                                                   loss                         the        normal        proportion                                     being                  80 to 90
of         nitrogen                          may              occur                  in            this            condition     cent.        One      is
                                                                                                                                                      week     wellper
                                                                                                                                                                later       the   figure       had      risen
known.                                This,              too,                 has             often                 been  to 60 per cent,          but
                                                                                                                                           attributed       it required         two      and      one-half
to            insufficiency                                 of          the     digestive           enzymes,          but months        before       normal        absorption            figures       were
other                      factors                     also               play       a part.            There        is obtained.
                                                                                                                            a                  The     urinary        nitrogen        loss      of 0.82       g
depletion                             not            merely                  of the       digestive         enzymes,      a day,       a substantial           loss      for an intake              of only
but              of          body                    enzymes                             in            general.                            The               proc- 1.42           g,      was            decreasing                          on an               identical                        intake                a
esses                of          assimilation                                of      food                  as       well             as          of        diges- week                 later.               The     final                      high              figure                for           urinary
tion              are             affected                       and               tissue                    synthesis                           through-            nitrogen                     is not relevant,                                   since    it reflects                             an         ex-
out                  the               body                   is             impaired.                  Of           the               limited                       ceptionally                     high   nitrogen                                   intake    given                             just          be-
amrioummt                         of           nitrogen                             absorbed                               a          substantial                    fore     the               third           period    of study.
                                                                                                                                                                         Further                        light        upon    the    anabolic                                                  defect                   in
                                                              TABLE                           I                                                                      these             patients                   is shown                      in      Table              II         which                   illus-
                                 Nitrogen                   Balance                      in       Kwasl:iorkor
                                        Patient                  R.-12                    months                    old                                                                                                 TABLE                     II

     Peri         )(l                                                                              II                                III                                               Tryptopl:an                      Load            Test           in

      I)ate                                     4/20-4/24                                4/27-5/1                         7/13-7/17                                               (Excretion                    of N         methyl             nicotinamide                          (mg)
      l)iet                                       Tortilla                               Tortilla                          Whole                                                          After          Ingestion                    of 1 g      L-tryptophan)

                                                        and                                   and                                milk                                                                                    Patient             R.
                                                        beans                                 beans
                                                                                         Whole                                                                                 Period                                   I                               II                             III
                                                                                                                                                                               Day          1                        0.81                            0.55                             1 .97
     \Veigh:t,                   av                     5.0             kg                    5.1            kg                  6.2             kg                            I)ay2                                 1.76                            0.78                            3.0(1
      N        it:take,                                 1.832                                 1.914                            3.330                                           Day3                                  5.18                            0.75                             1 .98
            g/day                                                                                                                                                              Day4                                  5.9()                           0.81                             1.53
     Stool              N,                              1 .240                                0.760                            0.487
      Untie                N,                           0.8:37                                (1.71)4                            2.83                                 trates              time result                   of       a tryptophan                                   load              test          car-
                                                                                                                                           843                       ried        out on admnissioii and                                        during                the         early     amid
      N       absorbed,                                 1)592                                      -   159
                                                                                                                                                                     later         recovery   phase.                                            Ingested                        L-tryptophami
      ‘       intake                                  :32.3                               60           4                                   4                          may            be used                for         tissue                 synthesis                    or         it         may             be
            tl)5( )rl)e(l                                                                                                                                            degraded                     iii     various                      ways,                  one          of         the            latter
      N retaitic(l,                                  -0.244                                   0.       456                  -(1.033                                  being                the           (legradation                            through                     kynuremmine                                to
                                                                                                                                                  -                   N-methyl                          nicotinamide                              (NMN),                         a      compound
502                                                          THE                    AMERICAN                                JOURNAL                       OF        CLINICAL               NUTRITION                                               IVol.         5, No.         5

readily                    mneasured                        in              the              urine                  by        its            fluores- organs                follows                 an       elevation                      of         the        protein

cence.                      When                  first           observed                            on            admission                      this take            with      great                  regularity.9       ‘   ‘#{176}     When                the          pro-
patiemit                   showed                   a       marked                          and      clear-cut         excre- tein       load                                         is     introduced                    by               the          oral          route             the
tion            of         NMN                     after                   the            tryptophan             load,       theconsequences                                               are            not too serious     because      of                                          the
increased                     excretion                      lasting                       for several         days.          Itimpaired                                            nitrogen                 absorption   which       I have                                              ii-
was             obvious                      from                     this               that                  the            kynurenine                   lustrated                  above,              which            limits                  the          uptake,                  but
metabolic                        pathway                          was               in        good                  working                    order.      when          hydrolyzed                        protein                or          amino                   acids            are
From                 the        second                    test,              carried                      out             a week                  later, introduced                      intravenously                     fatal                   consequences
one          muight                   be          tempted                           to           conclude                             that           this may      follow,      as                   was           discovered                            in      the          case           of
pathway                         had               failed                    since                the                test              was           com- concentration-camp                                 victims.         Even                               with    oral
pletely                    negative,                       no               increase                           in          NMN                    being feeding         of patients                          with    kwashiorkor                                   Dean     and
found.                      A           more                      reasonable                                        interpretation,                                            11     have           reported                   that               the          nonprotein
however,                        in         the           light                of          the              nitrogen                         balance        nitrogen                of the   bjood                    rises             to     pathologic                        levels
study                shown                 above,                 is that                     with              the          resumption                    for some                days   whjch                   suggests                   a measure                        of cau-
of      tissue              anabolic                      processes,                            as indicated                                 by       the tion         in     introducing                        protein               food              and           the          desir-
imimproved                       nitrogen                             retention,                                no            surplus             ofability       of                  using           both       carbohydrate                                     and           fat     at
tryptophan                            remained                             for       degradation                                    of       NMN. this      time,                     since           adaptation           to                      these           two            food-

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Such            degradation                               took               place              in the                    initial            period        stuffs           is more               quickly            achieved.
only            because                      the            anabolic                            processes                             were      not     Impairment              of     nitrogen           retention                                                            results
functioning                          properly.                                      In                the             final                period, from       failure     of anabolic           enzyme         systems.                                                             The
two      and                 one-half          months                                        later,                 when               the     ana- cause       of such      failure        may      be congenital                                                              or      ac-
bolic            needs                had               been                 to          a      considerable                               extent quired.             The     conditions            responsible                                                         for           such
taken                care             of         there                 is         evidence                           of       a        return              failure
                                                                                                                                                           of                differ          in     different              parts                  of     the          world            and
the       NMN                   excretion                         after                  the              tryptophan                              load. are       changing       with                       us     here.               In underdeveloped
       The             management                                      of           the              protein-starvation                                    countries       inadequate                               food             amid infection,                                 both
symmdronie                     as           usually     stated                                       is     to             give     protein                products                 of       ignorance                  and    a                  low        standard                        of
and     to                  give             it generously.                                                This               appears                     to
                                                                                                                                                           living,           are         responsible                  for this.                          With       us              these
make                 sense,                but            requires           a certain        amount        ofobvious       extrinsic                                                                      causes   are                       disappearing                           and
qualification.                           When                     food    of any       kind      is with-     we     are   learning                                                                       to search                         for     some                     intrinsic
held        the                      adaptive                        enzymes         responsible           forcause,     some silent                                                                      metabolic             anomaly                 of            which
metabolizing                            it suffer                   and    the tolerance           for that an ever-increasing                                                                             number                   are            coming               to light.
particular                           food            is      to        This Some
                                                                             some     of these       extent
                                                                                                   are transitory,           lost.
                                                                                                                             of longer       or shorter
phenomenon                                  has           been      time. duration,
                                                                              known           and      others
                                                                                                        for        are      permanent.
                                                                                                                           a long                   Meta-
In   the      case of carbohydrate          it    is known          as      bolic anomalies         interfere       with      gain     in we
Hofmeister’s         diabetes      or “starvation        diabetes.”         two     wys:j1Lhcausi                 ng impaired             appetite,
The    individual        who has been          deprived     of carbo- and           (2) by causing         masked       caloric     lossesTiiThe
hydrate                   reacts                   for            a         few      days     like                                a          diabetic #{233}ta.
when                 carbohydrate                                     is      freely      supplied                                          to him. i%iist            of metabolic       anomalies       is a long      one
In        the          case             of         fat            a         similar                       transitory                           loss   and
                                                                                                                                                      of       is increasing       every    year.       These     entities
tolerance      from                                 disuse was   described                                               by                  Ivar     are all rare,       but the chance        of encountering          one
Bang      of Sweden,8                                  a phenomenon                                                 which                we        our- of them       is not                       so rare.                Some                   metabolic                     anom-
selves               observed                      in      Baltimore.                                       The              situation                 inalies  although                             interfering                          with                 growth                 pro-
the     case      of protein         deprivation             is similar,         but duce      other        more       conspicuous            symptoms               which
more       serious      than      in the  case     of fat and        carbo-          attract         attention.             Diabetes           mellitus          and       ne-
hydrate          in that       adaptation       appears       to be less             phrosis         often       involvei1ous            caloric        losses        in
rapid,       if one        may      judge         from      animal       studies. tlliiirine.               Frequently             recurring             infections,
The      animal        presented           with       an additional            load such      as may          occur      in agammaglobulinemia                may
of protein          requires        more        liver    tissue     to deami- cause              serious        losses      in the       stools       as well          as in
nate         it amid             more               renal                  tissue               to         secrete                    the         addi-    the         urine.        We                  also     have                 to      consider                     a large
tiomial               urea             load.                      Hypertrophy                             of         these                  two            and          increasingly                      recognized                        group       of                “silent”
Septettiber           -(    )ct ber             1957 I                                                                           HULl’

metabolic                     anomalies                              where               the         symptoms                            are aim accomnpanying                                                        loss              of            sugar                   or          some                       other
insidious,        perhaps                                confined                       to   anorexia         with                             caloric
                                                                                                                                                a                           nutriment                      is there                                   likely    to                       be          a caloric
little     vomiting                                  and       chiefly                     characterized                                       deficit.
                                                                                                                                              by                                The                   metabolic                                        anomnaly                                   exerts       its
failure      to thrive.                                   Several                       of these        syndromes                              erelby                                   impairment                                                 nf appetite.
are        discussed                     in          the            present               symposium:                   idio-                       There                       is, however,        a                                        different      group      of                                                   con-
pathic              hypochlorernic                                   renal              acidosi,                   idiopathTc                  ditions                       associated       with                                           unexplained         failure                                                       to
hypercalcemia                             and      galactosemus.        The                                   various         gain    weight,      a group      even                                                                                        more                common                                    than
15iiiis   of renal                        glycosuria,         including                                      the              those
                                                                                                                     Debr#{233}-        referred     to    above.                                                                                            The                following                                   is a
deToni-Fanconi                                       syndrome                           should                be      men-    typical     example:
tioned              among                     the             conditions                      in     which                unusual
                                                                                                                                                       C’ase            Report:                 N.C.                    (#17594-55)                            was              admitted                              to
caloric             losses               in         the           excreta                take             place.                               Bellevue                      Hospital                      at          the            age             of       19        months                         because                    of
      A number                      of         metabolic                         anomalies,                       some                con-     failure                 to       gain            any                 appreciable                               an:ount                       of          weigh:t                  for
                                                                                                                                               the         past              year.               His                  family                   history                    and             the             history                      of
genital              amid          some                   acquired,                  are           associated                         with
                                                                                                                                               the         pregi:am:cy                       were               in           no         way                remarkable.                 His              birth
amninoaciduria.                               They                   include                 vitamin                    D-defi-
                                                                                                                                               weight                  was           6    lb.         15             oz.               He             was            breast                  fed              for          a     few
cient          rickets,                   vitamimi                         D-resistant                       rickets,                    theweeks                  only,                 being                  then                  put              on           an           evaporated                                    milk
Famicommi                  syndrome,                                 the          Hartnup                          syndrome,                   forniula,                     solids             and                  vitamins                          being               a(lded                      (luring                  tl:c

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galactosemia,                       phenylketonuria,                                     cystinosis,                      #{182}s-             fourth                  month.                    He                  failed                 to             thrive               almmst                        from               the
                                                                                                                                               start             and           durit:g               his             first            eight                months                   of       life             he       added
tinuria,               Wilson’s                               disease,                  and              various                      other
                                                                                                                                               only        3 lb to                 his       birth              weight.                               From               then            on            l:is         weight
fomis          of     liver.cliease,                                 the         aminoaciduria                    of      the
                                                                                                                                               remained                       stationary.                       :t           the              age            of         eight               months                         he
mieonatal                   period                        and           that            caused                    by        various            had          been               admitted                          tonother
                                                                                                                                                                                                                  a                           hospital                        for         study                      be-
ponotlld.                                                           The          loss         of     amino                acids                cause           of his              failure                 to          gain             weight,                      where                  lie         remained
in      some          of      these                   conditions                        may           be          as     much                  for
                                                                                                                                               as          the              succeeding                          11           months                         (Fig.               1).               He                was          the
                                                                                                                                               subject             of         considerable                               interest                      Qfl        the           part              of          the          hios-
ten        times             the         normal                       figure.                   However                     the           ab-
                                                                                                                                               pital           staff and                  was studied                             in          considerable                               detail.
solute             quantity                         of          amino             acids             so      lost           remains
                                                                                                                                                       Physical                    examination                          failed                   to          reveal                   am:               definite
small          and           does              not per              se cause             a serious                     caloric                 cause              for          his        malnutrition                        and                failure                 to           thrive.                         His
deficit.                   Only’in                   those              conditions                     where               there               is
                                                                                                                                                appetite                     was         not          good,                    but             with                 persistence                           a         reasox:-


                                                                N. C.                8/RTHOATE                          8-29-53


                                                I.                                                                                                                                                              hi







                                                          0                         rk#{232}                 /0                  ,6                                                              k                                z                   ii
                                                              AGE           IN          MONTHS

                                                                                                                                 Fig.          I.
54)4                                                                                    TI-IF                 AMERICAN                                      JOURNAL                                          OF              CLINICAL               NUTRITION                                                     I \ol.          5,      No.               5

able            an:ount                         of         nhiXe(l            diet              was           consumed.                              The               bowels
were                  quite                     normal.                                 From                  tune                to           time                  regurgitatiom:
of      food               was                 noted                and                some                 epigastric                          peristaltic                                waves
travelling                                      from::                   left                 to            right                     were                      seen.                       Barium
swallis-                         011             one              occasion                            revealed                          slight                   dilatation                                  of
the           esoph:agus                                     and              reflux                 of           barium                     from                    the            stomach.
A       laparototnv                                         was               perforn:ed                              at         the               age           of            17          months
because                         of            th:e             susl)icion                           th:at                Some                  inalfortuation                         of
the           gastrointestinal                                         tract                  was            preset:t                        but            no         such                 con-
(hitioti                       was                   discovere(h.                            .-t:           ititercurrent                             respiratory
infectiom:,                               possibly                        related                      to          aspiration                               was                associated
with:            fever                        for          a       time,                 but               this            did          not               persist.
       r’’Iaiiy                      laborat                       ry studies                                were                 undertaken                                         which:
failed                    to              reveal                       am:yth:ing                            abnormal.                       Therapy                                con-
siste(l                   in         altering                          tl:e            diet           to          teti:pt                the              child’s                    appetite,
gavage                           sh:en                       an               insufficient                                  quam:tity                            of                food                  was
takemi                ;              a         variety              of          drugs                      were                also                tried                   ir:cluding
antispasin(                                   )dics,                   tl:yr              )id               extract,           Thorazii:e                        R                 and
cortisone.                                    Noi:c                 of            these                    measures                                resulted                           in            any
gait:           iii            weight.

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       At              the                    age of                19            n:onth:s                 the              possibility                                   of          some
unusual                              metabolic                                    anomaly                            was                considered                                    and                 the
child             was                     transferred                                   to           Bellevue                          1-lospital                             for          study.
lie          then                    weighed                           10         lb      at:d              presented                          a pathetic                                  picture
(if          extret::e                               emaciation                                     am:d            apath:y.                               Agaim:                     physical
examination                                      amid              laboratory                                 studies                        revealed no                            evi-
(hence                     of             disease                        that                 would                      account                          for             the              picture.
The                   food                     was                reasonably                                  well                takem:,                       but                  some                    re-
gurgitation                                      was                noted.               On           close                 observation                               by            the
nursing                          staff                  it         was                  found                     that                tl:e           chil(l                    was              a        per-
sistem:t                       ruminator.                                This                  com:dition                             was                 treated                          by            a
coi:certe(l                                   effort               om:            the               part             of          the               nurses                       and             house
staff                 to         divert                         th:e          child                  after                 mneals                  and               whenever                                lie
started                         to             ruminate.                                He                 was                 picked                          up,                  carried
around,                          amid                  given                  a         great                 deal               of          personal                              attention.
The               th:erapy                                 was                successful                                 and             within                           a         few               (hays
rummatiom:                                       cease(l.                              Gain                  in           eight                      begat:                         some                     10
days              after                         adm:iissiom: am:d                                      continued                               without                                im:ter-
ruptiom:.                                In          the           course               of           the            miext              three                    months                          his
weight                         doubled.                                  He              was               discharged                                at          the                age             of       22
m::onths                        weighting                           211/2                 lb         (Fig.               2).                                                                                           In      conclusion,                     it       may             be       mioted                  that            the                para-
                                                                                                                                                                                                             doxical                      situation            is       not              infrequently                           encoun-
        It             is not                        our                 intent                        to            give                    the                impression
                                                                                                                                                                                                             tered                  of      a      child            who                although                          apparently                                    re-
that             rumination                                         is a frequent                                              cause                      of         failure                        to
                                                                                                                                                                                                             ceiving                     adequate            calories                  amid      with              ito          apparemit
gain                      weight.        The                                                  situation                                described                                          is cer-
                                                                                                                                                                                                 excessive                                  caloric             loss            imi the              excreta                    fails              to           gaul
tainly                       aim exceptional                                                         one.                              But      it                            is           by   no
                                                                                                                                                                                                             weight                   and          grow.                Examination                        of      a miumber                            of
mneans                           rare                   to             find                   a discrepancy                                                 between                                  the
                                                                                                                                                                                                             such               situations                      has               revealed                        that                  excreta                         of
amount         of food                                                      a child       is thought         to be taking
                                                                                                                               quite     normal       appearance          may       conceal                                                                                                                                                 mnarked
and      the     amount                                                        he actually           receives.            When
                                                                                                                               caloric     losses.        Other     instances           are                                                                                                                                              explained
accurate          records                                                     are     not    kept      the     impressions
                                                                                                                               by failure       to ingest     the calories        actually                                                                                                                                                 thought
about      quantities                                                        imigested       may     be very          faulty.
                                                                                                                               to be ingested        or to cstin:ate          accurately                                                                                                                                                       losses
And       whet:     there                                                   is regurgitation             it is extremely
                                                                                                                               sustained        by regurgitation.
difficult      to estimate                                                              with                  ammy                degree                             of             accu-
racy      the     caloric                                                      loss.     A meticulous                                                                      examnina-                                                                           REFER            ENCES
tion of time intake                                                           will often   provide    the                                                                 explana-
                                                                                                                                                                                                                  1.        Sxvm,         S. :        C    misidena      t   i( (ti5      ((ml   t   lie        duvel       (I)lflCti          t   (   )f
tion                       for                   the                   calories                                   that                   have                          apparently                                             dvstrophiia                  infamitummi.                 .1(1(1             Puediat.                (Supph.
vanished.                                                                                                                                                                                                                      100)         4:3:      575,          1954.
Septemuber-October                                     19571                                                                                        HOLT                                                                                                                                                 505

 2.   LEVINE,                S.         Z.,       WILSON,                    J.          R.,         and           GOTTSCHALL,                                                    SNYDERMAN,                       S.       E.,      and           HOLT,                  L.      E.,
                                                                                                                                                                                                                                                                                   JR.:             Con-
         G.:             The                  respiratory                                exchange                         in        marasmims.                                    genital             obliteration                          of         the         bile          ducts               with         par-
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 3.   HOLT,         L. E.,                 JR.,            TIDWELL,                       H.          C., and             SCOTT,           T.                                     41:774,                  1952.
         F.       M.:               Studies                      in        fat           metabolism.                 I.        Fat         me-                            7.   HOLT,           L.      E.,         JR.:             Cehiac               disease-what                                    is t?
         tabohism                   in nortnalinfants.                                    J.      Pediat.            6:    427,1935.                                              J.       Pediat.         46: 369,                 1955.
 4.   CHUNG,                 A.         W.,          MORALES,                       S.,         SNYDERMAN,                      S.         E.,                            8.   BANG,            I.:         Ueber                 Lipamie.                      III.               Die         GewOhnum:g
         LEwIs,               J. M.,                  and        HOLT,               L. E.,                JR.:           Studies              in                                 an        Fett.           Biochem.                     Zeitschr.           91:           112,             1918.
         steatorrhea;                             effect              of         level           of        dietary              fat        on            the              9.   OSBORNE,               T.           B.,      MENDEL,                    L.       B.,        PARK,              E.          A.,
        absorption                              of         fat         and                other               foodstuffs                       in         idio-                   and         WINTERNITZ,                         M.         C.:         Physiological                              effects
         pathic                   celiac               disease                     and               cystic               fibrosis                  of         the                of       diets       unusually                     richit:            proteimi                 or          inorganic
         pancreas.                         Pediatrics                      7:       491,               1951.                                                                      salts. J.           Blot.               Chem.      71:         317,          1927.
 5.   MORALES,                      S.,           CHUNG,                     A.               W.,       LEwis,                 J.        M.,                         10.       ADDIS,         T.,      LEE,               D.        D., LEW,             W.,        and           Poo,              L.      J.:
         MESSINA,                       A., and              HOLT,                 L.          E.,    JR.:            Absorption                                                  The           protein                   content                 of         organs                   and           tissues              at
        of        fat             and             vitamin                    A           in      premature                          infants.                         I.           different                   levels                of           protein                       consumption.               J.
         Effect              of         different                      levels                  of       fat           intake               on            the                      Nutrition                19:           199,        1940.
        retention                          of        fat          and               vitamin                       A.
                                                                                                                  Pediatrics                   6:                    11.       DEAN,          R.      F.         A., and            SCHWARTZ,                      R.:                The      effects
        86,         1954).                                                                                                                                                        of    protein              deficiency                     in     young               children.            C’ourrier
 6.   KRAHULIK,                         L.,            Snoon,                            M.            P., MORALES,                        S.,                                    4:293,              1954.

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