Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Failure to thrive
Treatment: Inpatient admission
The inpatient admission was medically necessary.

The patient is a male child born prematurely at 36 weeks' gestation with medical history significant for failure to thrive, gastroesophageal reflux, oral aversion, suspected milk protein allergy, iron deficiency anemia, and gross motor delay. He was hospitalized in previously with failure to thrive, at which time a nasogastric tube was placed for feeding. He pulled it out the next month, after which his gastroenterologist (GI) allowed a trial of oral feeding and omeprazole. He lost weight over the ensuing weeks, and was referred to the ED about two months later for nasogastric tube replacement and endoscopy because of ongoing failure to thrive. 

The patient's vital signs included temperature 100.2, heart rate 142, respiratory rate 25, and 98% saturation in room air. His physical examination was unremarkable. Laboratory evaluation revealed metabolic acidosis (CO2 [carbon dioxide] 17), leukocytosis (WBC [white blood count] 17.8K), thrombocytosis (platelets 450K), mildly elevated AST (aspartate aminotransferase) (38) and alkaline phosphatase (196), and normal GGT (gamma-glutamyltransferase). 

The patient was admitted for ongoing management of failure to thrive. Admission orders included IV fluids, nothing by mouth after 0400 in anticipation of endoscopy, and Protonix. Prior to the scheduled procedure, he was given a trial of Pediasure orally, which he did not tolerate (unable to swallow). The endoscopy was grossly normal with no overt signs of milk protein allergy. A nasogastric tube was placed and position confirmed. He was deemed stable for discharge following tube placement, to continue enteral feedings with Neocate and follow-up with GI clinic. 

Failure to thrive generally refers to growth below the 3rd-5th percentile, or crossing of two major percentiles over a short period of time. Etiology may be organic or psychosocial, or a combination of both. The list of organic causes of failure to thrive is quite long, and includes gastroesophageal reflux disease, metabolic disorders, and chromosomal disorders, all of which were under consideration in this case. Hospitalization is indicated in cases of severe malnutrition, coordinated diagnostic and laboratory evaluation, lack of catch-up growth, and evaluation of parent-child interaction. Goals of hospitalization include identification, if possible, of etiology, formulation of an appropriate feeding strategy with demonstrated pattern of weight gain, and correction of any metabolic derangements. Family education is also essential. Early identification and treatment of failure to thrive are essential to prevent the substantial complications that would otherwise arise.

This young male child born prematurely had been followed closely for failure to thrive since infancy. He had been hospitalized on one other occasion, at which time a nasogastric tube was placed for enteral nutrition. When he pulled the tube out the next month, he was given a trial of oral feeding. However, he failed to gain weight, actually losing a small amount by the time of this admission. He was referred to the ED from GI clinic in anticipation of upper endoscopy and nasogastric tube insertion. While in the hospital, he was given a trial of Pediasure orally, which he did not tolerate. A Nutrition consultation was sought to optimize his nutrition once the nasogastric tube was inserted. He underwent endoscopy, with no obvious findings consistent with milk protein allergy, and the nasogastric tube was inserted. Once he recovered from sedation, he was discharged home to continue enteral feedings. He could not have been safely managed in the outpatient setting, because he had already failed. He required more involved intervention than what could be provided in the clinic setting. The hospital admission was therefore medically necessary and appropriate to manage this child's complex needs.