Mother of A Baby Who Is Not Gaining Weight — Free SCA Practice Case
Mother of a baby who is not gaining weight
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Materials for Candidate
Please review before starting the consultation
Full Name
Rory Whittaker
Age
15 years
Consultation Type
VideoAge
15 months
Situation
Video Consultation. Booked after a weight check.
Reason for Encounter
"My little boy has had diarrhoea for ages and he's not putting on weight. I think it might be a food allergy."
Medical Records (Rory Whittaker)
- ●PMH: None recorded. Immunisations up to date. Newborn screening negative.
- ●Medications: None.
- ●Allergies: NKDA.
- ●Recent notes: Reviewed several weeks ago with chronic loose stools and weight faltering; food diary advised; weight to be rechecked. Weight now plotted between the 0.4th and 2nd centiles (birth weight on the 25th centile); no dehydration; abdomen soft; chest clear.
Patient Script
For the friend playing the patient role
Character Overview: You are Gemma, mother of Rory, who is 15 months old — your first and only child. Since he started solid foods at around six months, he has had loose, non-bloody stools (three or four a week) and has not been gaining weight as expected; his symptoms have been much the same for months. He eats cereals (including wheat-based ones) and pasta and has no trouble swallowing. He has no vomiting, no rashes, and no breathing problems. You suspect a food allergy because you have read about it online, and your sister's child cannot eat certain foods (you are not sure of the condition's name). You are worried about his weight and want something done or a referral.
Opening Sentence: "Hello Doctor. I was asked to book after Rory's weight check. He's had diarrhoea for months, since he started solids, and he's just not putting on weight. I've read about food allergies online and I'm wondering if that's what it is — can something be done?"
History if Asked (Data Gathering Phase)
- ●The problem: "Loose stools, three or four times a week, since he started solids at six months. And he's not gaining weight — it's been much the same for months."
- ●His diet: "He eats cereals — including wheaty ones — and pasta. He eats and swallows fine, good appetite really."
- ●Other symptoms: "No vomiting, no rashes, no trouble breathing. The stools aren't bloody."
- ●What she thinks: "I've read about food allergies. My sister's little boy can't eat certain foods — I don't know the name of it."
- ●What she wants: "I want something done about his weight, or him referred to a specialist."
ICE — Ideas, Concerns, Expectations
The caller does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.
- ●Ideas: Gemma believes it is a food allergy. "I'm fairly sure it's a food allergy of some sort."
- ●Concerns: Her dominant concern is his ongoing failure to gain weight. "I'm really worried he's not putting on weight."
- ●Expectations: She wants action or a referral. "I'd like something done, or for him to see a specialist."
If Asked — Faltering-Growth and Cause Screen
The caller answers these only when directly asked.
- ●If asked about when the diarrhoea/weight problem started (relative to weaning): "It started when he went onto solids at six months." (Temporal link to gluten introduction.)
- ●If asked about stool frequency and blood/mucus: "Three or four loose stools a week, no blood or mucus."
- ●If asked about vomiting, abdominal pain, or distension: "No vomiting, and he doesn't seem in pain, though his tummy can look a bit bloated."
- ●If asked about allergy/anaphylaxis features (rash after feeds, wheeze, swelling): "No rashes after food, no wheeze, no swelling." (Argues against IgE food allergy.)
- ●If asked about appetite, diet detail, and fluids/wet nappies: "Good appetite, eats a range including wheat and pasta, drinks well, normal wet nappies."
- ●If asked about recurrent infections (chest, especially — cystic fibrosis): "No recurrent chest infections."
- ●If asked about newborn screening: "His newborn heel-prick screening was all normal."
- ●If asked about family history of bowel disease/coeliac: "Not that I know of, but my sister's child has a food condition."
- ●If asked about development and general wellbeing: "He's meeting his milestones and is otherwise well in himself."
- ●If asked about home/social: "He lives with me and my husband; he's our only child."
Responses to Management (The Negotiation Phase)
- ●If the Doctor explains this is faltering growth and possibly coeliac disease: "Faltering growth? And it could be coeliac disease — is that the food thing my sister's child has?" (The tested point is explaining faltering growth and raising coeliac disease as a likely cause.)
- ●If the Doctor advises coeliac testing: "So he needs a blood test for coeliac disease?" (The tested point is arranging coeliac serology as part of the work-up.)
- ●If the mother asks about removing gluten — the key counselling point: "Should I stop giving him bread and wheaty foods then?" (The tested point is advising her NOT to remove gluten before testing, or the test will be unreliable.)
- ●If the Doctor discusses referral and the wider team: "Would he see a specialist, and would a dietitian be involved?"
- ●If the Doctor arranges follow-up/growth monitoring: "How will you keep an eye on his weight?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Faltering Growth
- ●Faltering growth is a slower-than-expected rate of weight gain (or weight/weight-gain falling across centiles) in infancy/childhood. Assess by plotting serial measurements (weight, length, head circumference) and interpreting centile crossing.
Organic vs Feeding-Pattern Causes
- ●Distinguish inadequate intake/feeding-pattern causes (feeding technique, volume, behaviour, psychosocial) from organic causes. A careful feeding history is central. Organic causes include coeliac disease, cow's-milk/food allergy, cystic fibrosis, chronic GI disease, and recurrent infection.
Coeliac Disease
- ●Coeliac disease classically presents with chronic diarrhoea and faltering growth beginning after gluten introduction (weaning). Diagnose with coeliac serology (anti-tTG IgA with total IgA), with specialist-led confirmation.
Do Not Remove Gluten Before Testing — Key
- ●The patient must continue eating gluten until coeliac testing is complete — removing gluten beforehand makes the serology (and any biopsy) unreliable/falsely negative. This is a critical counselling point.
Screen for Cystic Fibrosis and Allergy
- ●Ask about recurrent chest infections and confirm newborn screening (cystic fibrosis), and screen for allergy/anaphylaxis features (arguing for or against food allergy).
Multidisciplinary Management and Referral
- ●Involve the health visitor and paediatric dietitian, arrange serial growth monitoring, and refer to paediatrics for a faltering-growth work-up with a likely organic cause.
Safety-Netting and Follow-Up
- ●Safety-net for dehydration, systemic illness, or blood in stools, and arrange follow-up for results and growth review.
Common Candidate Mistakes in This Case
- ●Advising gluten removal before testing: the central error, rendering coeliac testing unreliable.
- ●Not taking a feeding history: failing to distinguish organic from feeding-pattern causes.
- ●Missing the coeliac pattern: overlooking the temporal link to gluten introduction.
- ●Dismissing the mother's idea: rejecting the food-allergy concern instead of engaging with it.
- ●No growth monitoring, referral, or follow-up: leaving faltering growth unmonitored and unreferred.