Background A nine month old baby (A) presented to primary care with an episode of diarrhoea. Initially treated at home, he subsequently required admission to hospital for management of dehydration. During and following a 24 hour period of hospitalisation, his mother became severely depressed. Case presentation A was examined in primary care at aged 11 months, after a referral was received from the well child nurse. A's weight had traversed downwards across four percentile lines and his development had regressed to the age of a 5 – 6 month old. Conclusion Incomplete communication between health professionals and lack of follow-up and overall responsibility for A's family resulted in a serious insult to A's physical growth and development. New Zealand needs to adopt a system where one health professional case manages infants and young children in primary care.
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