Father of A 10 Month Old Who Has Dropped Two Centiles — Free SCA Practice Case

Character Overview: You are Stuart Hallett, a 34 year old father calling about your daughter Nell, who is 10 months old. You work nights as a baker at a large commercial bakery, from 10pm to 6am, four nights a week, and sleep through the early afternoon. Your partner Marnie, 32, is a teaching assistant on maternity leave. Nell is your first child. You are tired, anxious and a little defensive, because you feel the family should have managed this without a doctor. The health visitor weighed Nell two days ago, said she had dropped from the 50th to the 9th centile, and told you to book in with the GP. You want a plan and a reason. You speak plainly, and you go quiet and a bit choked when you talk about Marnie. Marnie is asleep and did not feel able to join.

Opening Sentence: "Hello, doctor. The health visitor weighed Nell and says she's dropped from the middle of the chart down to the bottom end, and she said to see you. She won't eat her food, she just wants her milk, and honestly we don't know what we're doing wrong."

History if Asked (Data Gathering Phase)

• ●The problem: "Nell is ten months. She was good with food when we started at six months, then over the last two months or so she's gone off it. She turns her head, shuts her mouth, bats the spoon away. She'll take a couple of spoonfuls and that's it. Meals take half an hour or forty minutes and often end in tears. She usually has a bottle about an hour before food."
• ●How much milk: "She has about five bottles in the day, eight ounces each, and one in the night, so six really. She has one before her naps to settle her. And if she won't eat, Marnie gives her a bottle so at least she's had something."
• ●Type of milk and how it is made: "Ordinary first infant milk from the supermarket, bought a tin at a time. We make it exactly as the tin says, one level scoop to each thirty mils of water. We cool it first. We've never added anything or watered it down. She has a few sips of water from a beaker with meals, no juice."
• ●What she eats: "Breakfast is two or three spoons of baby porridge. Lunch is a few spoonfuls of puree or half a finger of toast that she mostly squashes. Tea is a few spoonfuls of mashed vegetables or pasta. No snacks, as Marnie says Nell is too full of milk."
• ●How it started and textures: "At six months she loved carrot and sweet potato puree. We stayed on smooth puree until about nine months. When we moved to lumpy food she gagged, pulled faces and spat it out. She is fine with a banana or toast fingers, but not for long."
• ●Mealtimes: "She's in her high chair in the kitchen. It's usually just Marnie, because I'm asleep at lunchtime and at work at tea time. Marnie puts videos on her phone to keep Nell distracted while she tries to get the spoon in."
• ●Pressure at meals: "I've seen it on my days off. Marnie gets upset and sometimes holds the spoon at Nell's mouth until she opens up. She hates doing it."
• ●Birth and early weights: "Full term, 39 weeks, normal delivery, no problems. She was 3.3 kilos, bang on the middle. Breastfed for about three weeks, then Marnie's milk wouldn't keep up and we moved to formula. She put on weight steadily until about six months."
• ●Development: "She sat up by herself at about seven months, babbles away, waves, picks up things with her finger and thumb. She shuffles on her bottom but isn't crawling yet."
• ●Family history: "No coeliac, no cystic fibrosis, no bowel problems that I know of. I'm five foot eleven and Marnie is five foot five."

Ideas, Concerns, Expectations

Gating note: Stuart does not raise any of the following himself. Each part comes out only when the doctor asks what he thinks is going on, what is worrying him, or what he was hoping for.

• ●Ideas: He thinks she is just a fussy eater, but he also wonders whether something is wrong inside her tummy, because she won't take food. "She's either stubborn or there's something wrong with her insides that we can't see."
• ●Concerns: He fears there is a serious problem. A cousin's little boy needed a feeding tube, and the picture of that has stuck with him. He is also worried about Marnie, who is blaming herself. "My cousin's lad ended up with a tube in his stomach. I keep thinking that. And Marnie's taken it so badly. She says she's failing as a mum."
• ●Expectations: He hoped for tests, perhaps blood tests, to find out if something is wrong, and wants a clear plan. He would take a special high calorie milk if it was offered. "I thought you might do some blood tests. Or give us one of those milks with extra calories in. Mainly I just want someone to tell us what to do."

Associated Symptoms (Red Flags)

Gating note: Stuart answers these only when asked. Every one is negative unless stated.

• ●If asked about vomiting: "She brings up a little bit of milk after a bottle sometimes, a small dribble. It isn't forceful, it's never green or bloody, and it doesn't happen after food."
• ●If asked about stools and wet nappies: "One or two a day, soft and brown, no blood, no change that I've noticed. Five or six wet nappies a day, and they're not dark or smelly."
• ●If asked about diarrhoea, greasy stools or a swollen tummy: "No, her tummy is normal."
• ●If asked about cough, wheeze, breathing, chest infections, fever or urinary symptoms: "None. She's never needed antibiotics or been to hospital. She's well in herself."
• ●If asked about rashes or eczema: "A bit of dry skin on her cheeks sometimes, nothing that needs a cream."
• ●If asked about coughing, choking or noisy swallowing during feeds: "No. She gags on lumps but she doesn't choke or cough on milk."
• ●If asked about tiredness or allergic reactions: "She's lively, up at six and full of beans. No swelling or hives."

Parents and Home Life

• ●Marnie's mood: "She's not herself. She's tearful, she's not sleeping even when Nell is, she's stopped seeing her friends and she says she's useless because she can't get Nell to eat. I'd say it's been getting worse for about two months. She won't say she's depressed. She won't see anyone about it."
• ●Risk to Marnie or Nell: If asked directly about thoughts of self harm or of harming Nell: "No, nothing like that. She'd never say anything like that, and I'd be the first to know. She's just flat out exhausted and low." He is certain Nell is safe with her.
• ●Night feeds and support: "Marnie does the night bottle on her own on my work nights. I do it on the three nights I'm home. I sleep through the morning and the early afternoon, so I'm no use in the day." Marnie's mother lives an hour and a half away and visits most Sundays. Marnie has not told her how bad things are.
• ●Money and food: No money worries and no smokers in the house. "I'm knackered but I'm managing. I'm more worried about her than me."
• ●Availability to be seen: Stuart can bring Nell to the surgery tomorrow afternoon, or on Thursday morning when the health visitor clinic runs at the children's centre.
• ●Declines remote examination: If asked to check Nell on screen: "I don't know what I'm looking for, can't you see her in person?"

Responses to Management (The Negotiation Phase)

• ●If the doctor explains that too much milk may be reducing her appetite and suggests cutting the bottles down:
  • ●Reaction: Alarmed. "But she barely eats. If I cut her milk she'll starve." He accepts if told the change is gradual, that she will still get milk, and that food is offered before a bottle. He asks how many bottles she should have. On the night bottle: "Marnie won't cope with Nell screaming in the middle of the night." He accepts a gradual plan.
• ●If the doctor suggests tests or asks about blood tests:
  • ●Reaction: Anxious. "Shouldn't she have bloods, to be safe?" If told she looks well, needs a proper check and weight first, and that tests are only done if the examination or the history point to something: "And if she doesn't pick up?" He is reassured that a paediatrician would see her if she did not respond.
• ●If the doctor discusses a high calorie milk, a supplement or a dietitian:
  • ●Reaction: Hopeful. "Can't you give us one of those milks with extra calories?" If told that changing how she feeds comes first and that a dietitian can help if she does not gain: "Right. That makes sense, as long as we're not just waiting."
• ●If the doctor asks about Marnie or raises her mood:
  • ●Reaction: Quiet, then grateful. "She'll say she's fine." He agrees she should talk to someone. If asked about the health visitor: "She might talk to her. She won't want a fuss." If offered help with night feeds: "I could take a night off." If told Marnie can see her own GP: "I'll pass that on."
• ●If the doctor suggests feeding changes at mealtimes (family meals, no screens, finger foods, not forcing):
  • ●Reaction: Receptive but practical. "Marnie's on her own for most of it, and she'll feel I'm saying she's doing it wrong." He agrees to family meals on his days off and will tell Marnie it is not her fault. He asks what to do when Nell refuses: "Do we just take it away?"
• ●If the doctor gives a follow up plan and safety netting:
  • ●Reaction: Wants specifics. "How will we know it's working? And what should make us come straight in?" If advice is vague, he asks "Worse how?" He repeats back any specific list clearly and is happy to have her weighed again in about two weeks.