Failure to Thrive - PowerPoint - PowerPoint

							Joyee G. Vachani, MD
      April 21st, 2010
Does this patient have FTT?
Does this patient have FTT?
Does this patient have FTT?
 <3rdor 5th percentile on growth chart
 Change in growth that has crossed two %s
 Gomez criteria: compare current wt for age
  with expected weight for age (at 50th %)
     weight <60% of expected = severe FTT
     61-75% = moderate FTT
     76-90%    = mild FTT
 Look at trends over time
 Use appropriate growth charts
    Premies: corrected age on term growth charts
    Trisomy 21
 Weight      decreases first  Length
    Low wt only: acute undernutrition
    Low wt and ht: chronic malnutrion/stunting
    Low wt, ht, and HC:
        Congenital or genetic abnormalities
        Severe malnutrition
 You are about to see a patient admitted to
 FIS for Failure to Thrive… where do you start?
 Dietary Hx
 Psychosocial Hx
 Birth Hx
 Family Hx
 ROS
    Development
    Recurrent infections
    GI hx
    Resp hx
 www.cdc.gov/growthcharts
 Dymorphic   features
 OP: clefts, suck, caries
 Chest, Abd, Neuro
 Skin: loose skin = muscle wastage
 Edema = protein deficiency
 Observe interaction between parent and
  child
 Youhave completed your H+P and are
 formulating an assessment and plan… What
 are your next steps?
 Minimal, if any, labs if a proper H+P is done!
 Screening tests
     CBC, ESR, CMP, UA and Urine Cx
     Stool: fat, cx
     Sweat test
 Other    possible tests
     Igs, TFTs, Fe/Lead
     PPD, HIV
     UOA, Karyotype
     Bone Age
 Inadequate caloric intake (most common)
 Inadequate caloric absorption/utilization
 Increased caloric requirements (ie. excess
  metabolic demand)

 Physiologic   causes that are not FTT
     Prematurity
     Familial short stature
     Constitutional growth delay
     SGA
 Inappropriate   volume or type of food
    Incorrect formula preparation
    Excess juice or water
 Poor feeding technique
 Oromotor dysfunction or cleft palate
 Psychosocial
 Vomiting
     GERD
     Obstruction
     Increased ICP, meds, illnesses – UTI, metabolic
      disorders (storage diseases, amino acid disorders)
 IBD, CF, Celiac disease, Short gut
 MPA, Lactose intolerance, Allergic colitis
 Liver disease
 Vitamin or mineral deficiencies
 Cardiac disease
 Chronic lung disease
 Endocrine disorders – DM, DI, hyperthyroid,
  adrenal/pituitary disease
 Anemia, Hgb SS, Thalassemia
 Genetic/chromosomal abnormalities (Tri 21)
 Any chronic disease
 Catch   up growth
    10 days to 1 month     120 kcal/kg/day
    1-2 months             115 kcal/kg/day
    2-3 months             105 kcal/kg/day
    3-6 months              95 kcal/kg/day
    6 months to 5 yrs       90 kcal/kg/day
 Vitamin   and mineral supplementation
    Fe and Zinc
 Monitor   for refeeding
 Most cases of FTT can be managed
  outpatient
 Admit
    Severe FTT/Malnutrition
    Moderate dehydration
    Infection
    Further diagnostic and laboratory evaluation
    Lack of catch-up growth
    Evaluation of parent-child feeding interaction
 Adequate,   consistent weight gain
  demonstrated
 Diagnostic tests and consultations complete
 Proper follow-up arranged
 The caretaker demonstrates understanding of
  nutrition recommendations and growth
  expectations
 FTT  in 1st year of life (regardless of cause) is
  particularly ominous
 Maximal brain growth occurs in first 6 months
  of life
 1/3 children with psychosocial FTT are
  developmentally delayed and have social and
  emotional problems
Does this patient have FTT?




      Wt, Ht, and HC
     = congenital abnormality*
Does this patient have FTT?




      Wt across 2 percentiles, then off curve   ht
     = FTT
Does this patient have FTT?




     Wt and Ht which follows curve, then improves
     = constitutional growth delay
   You are evaluating a 6 month old child who has a
    VSD and is scheduled for cardiac surgery. The
    child’s weight is 6 kg (3rd%), length is 30th%, and
    HC is 50th%. His mother states she prepares the
    formula by adding 1 scoop of powder to 2 oz
    water. She estimates that he drinks 24 oz of
    formula per day. You estimate the baby’s intake
    is approx 500 kcal per day of cow milk formula,
    which is the RDA for his age. According to his
    mother, he spits up three times per day and
    passes two soft stools daily. On physical exam,
    you hear a 3/6 holosystolic murmur and palpate
    the liver 1 cm below the RCM.
 Ofthe following, the BEST explanation for
 the child’s malnutrition is:

 A. Caloric requirement exceeding RDA
 B. Cow milk protein intolerance
 C. Incorrect preparation
 D. Pathologic gastro-esophageal reflux
 E. Undiagnosed pancreatic insufficiency
 Ofthe following, the BEST explanation for
 the child’s malnutrition is:

 A.   Caloric requirement exceeding RDA
 B. Cow milk protein intolerance
 C. Incorrect preparation
 D. Pathologic gastro-esophageal reflux
 E. Undiagnosed pancreatic insufficiency
 A.   Caloric requirement exceeding RDA

 Thechild in this scenario has a large VSD – a
 chronic illness which increases his metabolic
 demand and therefore caloric requirements
 (RDA).
   During the health supervision visit of a 2-week-
    old infant, you note that his weight remains
    below his birthweight. The baby was delivered
    by a midwife in the parents’ home. There were
    no complications, and the parents have declined
    all perinatal testing. His mother says he
    breastfeeds well, and her milk supply is good
    compared with that for her previous two
    children. Recently, though, the infant has been
    vomiting after feedings. On physical
    examination, he has total body jaundice, and his
    liver is enlarged to palpation. He is alert.
 Ofthe following, the test that is MOST likely
 to aid in diagnosis is:

 A. Abdominal ultrasound
 B. Serum transaminases measurement
 C. Total/direct bilirubin
 D. Urine organic acid measurement
 E. Urine reducing substance measurement
 Ofthe following, the test that is MOST likely
 to aid in diagnosis is:

 A. Abdominal ultrasound
 B. Serum transaminases measurement
 C. Total/direct bilirubin
 D. Urine organic acid measurement
 E. Urine reducing substance measurement
 E.   Urine reducing substance measurement

 Thechild in this scenario has findings
 suggestive of classic galactosemia: within
 days of initiation of milk feedings, the infant
 has vomiting, then develops hepatomegaly,
 and FTT. Galactosemia results in the inability
 to oxidize galactose and the accumulation of
 galactose in organs such as the liver, kidneys,
 brain, and eyes. Galactose is a urine
 reducing substance.
 DDx    for FTT – think calories!
     Caloric intake (most common)
     Caloric absorption/utilization
     Caloric requirements ( metabolic demand)
A systematic approach to H+P often leads to
 diagnosis
    Detailed feeding hx is especially key
 Labs should be minimal and guided by H+P
 Children with FTT need solid follow-up to
  follow weight and developmental progression
 2009 PREP Self-Assessment.
 http://emedicine.medscape.com/article/985
  007-media
 Kliegman: Nelson Textbook of Pediatrics, 18th
  ed. Chapter 37 – Failure to Thrive. 2007.
 Olsson, JM. Failure to Thrive. Pediatric
  Hospital Medicine. 2nd edition. 2008: 97-100.
 Stewart, CS. Failure To Thrive. The 5 Minute
  Pediatric Consult. 5th edition. Ed Schwartz,
  MW. 2008: 318-319.
“You know you’re a pediatric hospitalist when…

...you've got the art of inpatient FTT down to an
  amazing, precise science: Give it milk. Watch
  it grow.”

From the AAP Hospitalist Medicine Listserve
Gregory Plemmons, MD