Makindo Medical Notes

🩺 OSCE Station – Failure to Thrive (Child)

Candidate Instructions 📋

You are a final-year medical student in the paediatric outpatient clinic. You are asked to see a 2-year-old child who has been referred by the GP for poor growth. Take a focused history from the mother, explore possible causes of poor growth, and outline your initial approach. You do not need to perform an examination. You have 8 minutes.

Key OSCE Learning Points 🔑

• Failure to thrive (FTT) = weight (or weight-for-height) < 2nd centile, or crossing ≥2 centile spaces on the growth chart 📉.
• Causes: inadequate intake, malabsorption, increased requirements, chronic disease, safeguarding concerns.
• Always think of nutrition, medical conditions, and social environment.

History Framework 📝

• Presenting Concern: When did growth faltering start? Feeding difficulties?
• Dietary History: Breast or bottle? Weaning? Appetite? Typical daily intake? Food refusal?
• GI Symptoms: Vomiting, diarrhoea, steatorrhoea, constipation, blood in stool.
• Respiratory: Chronic cough, recurrent chest infections (think cystic fibrosis).
• Systemic: Recurrent infections, fatigue, night sweats, polyuria/polydipsia.
• Pregnancy/Birth: Gestation, birth weight, neonatal complications.
• Development: Milestones (gross motor, fine motor, speech, social).
• Social & Safeguarding: Who lives at home? Parental coping? Domestic violence? Neglect? Food insecurity?
• Family History: Coeliac, cystic fibrosis, thyroid disease, IBD.

Examiner Prompts 👩‍⚕️

• Child is 2 years old, dropped from 50th centile at birth to below 2nd centile by 18 months.
• Mum says child is “fussy with food”, often refuses meals but drinks lots of juice.
• No diarrhoea, vomiting, or recurrent infections.
• Normal pregnancy and birth, no neonatal complications.
• No concerns about development. No safeguarding red flags disclosed on direct questioning.

Causes of FTT ⚖️

• Inadequate intake: Poor feeding technique, fussy eater, neglect, poverty.
• Malabsorption: Coeliac disease, cystic fibrosis, cow’s milk protein allergy.
• Increased requirements: Congenital heart disease, chronic infections, hyperthyroidism.
• Psychosocial: Neglect, parental mental health, attachment difficulties.

Investigations 🔬

• Basic: FBC, U&E, LFT, CRP, ESR.
• Specific: Coeliac screen (tTG IgA), sweat test (CF), TFTs, stool cultures if diarrhoea.
• Growth Chart: Plot height, weight, head circumference accurately.
• Safeguarding: Multi-agency assessment if concerns arise.

Management 🚑

• Immediate: Exclude safeguarding concerns ⚠️. Ensure child is safe.
• Dietary: Refer to dietitian; advise 3 meals + 2–3 snacks/day, reduce juice intake.
• Medical: Treat underlying causes (e.g., gluten-free diet for coeliac, pancreatic enzymes for CF).
• Support: Health visitor review, parental education, involve social services if neglect suspected.
• Follow-up: Regular growth monitoring (monthly initially).

Examiner’s Marking Guide 📋

• Introduces self, gains consent, uses open → focused questions.
• Explores dietary intake and feeding behaviours in detail.
• Asks about GI, respiratory, systemic symptoms.
• Considers safeguarding explicitly.
• Mentions growth chart use + NICE investigations.
• Outlines dietitian input and follow-up plan.

References 📚

• NICE CKS – Faltering Growth
• RCPCH Growth Chart Guidance.