Normal Growth Patterns Definitions Classification of FTT Etiology History Physical Exam Lab work Treatment 10% of children in primary care settings show signs of failure to thrive FTT accounts for 1-5% of pediatric hospital admissions FTT is a common sign and remains diagnostic and therapeutic challenge. The Diseases of Infancy and Childhood by L. Emmett Holt in 1897- reference to an infant who "ceased to thrive“. “Fail to thrive" first in 1933 in 10th edition. 1967- psychosocial aspects of failure to thrive became synonymous with maternal deprivation syndrome /parental" deprivation syndrome DSM-III as "reactive attachment disorder Term infants: Lose 5-10% of birth wt, regain by 10-14 days. Infants wt gain pattern: 1 kg/mo for the first 3 months 0.5 kg/mo from age 3-6 months 0.33 kg/mo from age 6-9 months 0.25 kg/mo from age 9-12 months Double the birth weight by 4-5 mo Triple the birth weight by 1 yr of age Term infants : 1st 3 months gain 25-30 g/day 3- 6 months gain 15-20 g/day 6months to 1 year of age, 12g/day 0.25 kg/mo until toddler 2 kg/y through early school age. Growth of Length : 25 cm in first 1 yr 12.5 cm in 2nd yr 5-6 cm between 4yrs and puberty onset upto 12 cm at onset of puberty Head Circumference: Average at birth 35cm 47 cm by age 1 year, rate then slows Average of 55 cm by age 6 years Caloric Requirements: 100-110 kcal/kg/d for the first half year 100 kcal/kg/d for the second half of the first year Beyond 10 kg, 50 kcal/kg/d is required until 20 kg Beyond 20 kg, 20 kcal/kg/d are necessary. Premature infant usually require 120-140 kcal/kg/day prior to 40 wks gestation. Sign of unexplained weight loss or poor weight gain in a child or infant . 1. A child younger than 2 years of age whose weight is less than the 3rd or 5th percentile for age on > 1 occasion. 2. A child younger than 2 years of age with weight is less than 80% of the ideal weight for age. 3. A child younger than 2 years whose weight for age percentile crosses two major percentiles lines on a standard weight curves below a previously established growth rate. Weight for Length: weight-for-length < 80% of ideal weight - Actual weight <70% of predicted weight-for-length requires urgent attention Weight for age decreases early in the course of FTT, followed by height. child with genetically short stature, SGA infants, Preterm infants, and “over-weight” infants , whose height gain exceeds weight gain. Preterm infants : Plot using corrected age until 2 yrs of age if birth wt >1000gm until 3 yrs of age if birth wt < 1000gm Catch up growth for Primi: 18 mns for Head circumference 24mns for weight 40 mns for height Historically : Organic and Nonorganic Organic FTT: underling major disease process Non organic FTT / Psychosocial FTT: environmental or social factors , no medical problem not mutually exclusive false dichotomy. Mixed may be present when the effects of organic disease are combined with concurrent psychosocial problems. FTT is a spectrum , with purely organic and purely environmental being the extremes. National Center for Health Statistics (NCHS) developed growth charts in 1977. 2000 CDC growth charts represent the revised version of the 1977 Data from National Health and Nutrition Examination Survey (NHANES) is used to revise the charts. Infants, birth to 36 months Weight-for-age Length-for-age Weight-for-length Head circumference-for-age Children and adolescents, 2 to 20 years Weight-for-age Stature-for-age Body mass index-for-age MILD MODERATE SEVERE WEIGHT 75-90% 60-74% <60% HEIGHT 90-95% 85-89% <85% WEIGHT /HEIGHT 81-90% 70-80% <70% Trisomy 21, Prader-Willi Williams syndrome Turner Meningomyelocele Marfan Achondroplasia. Prevalence depends on population sampled. 5-10% of primis and children living in poverty in developed nations. Developing nations with high rates of malnutrition and or HIV infection. Nonorganic FTT is far more common in USA and other industrialized countries. Genetic/Metabolic/ Chromosomal disorders Respiratory Inborn errors of metabolism Obstructive: Tonsillar Congenital syndromes hypertrophy, OSA Sickle cell disease CF Fetal alcohol syndrome Asthma BPD CNS Chronic resp failure CP Infectious Disease Hypothalamic /CNS TORCH tumors Chronic infections Neuromuscular disorders Parasitic infections Lead toxicity TB/HIV Cardiac Endocrine CHF Hypothyroidism/Hyperthy Cyanotic heart disease ro Vascular rings Diabetes Renal Rickets UTI/ Chronic Growth hormone pyelonephritis deficiency RTA Adrenal insufficiency Renal Failure Pyloric stenosis GERD Malabsorption Celiac disease Milk intolerance: lactose, protein Inflammatory Bowel Disease Short bowel syndrome Food allergy Hirschsprung Chronic cholestasis Pancreatic insufficiency Chronic infant/ toddler diarrhea Inadequate calorie intake Inadequate calorie absorption Excessive calorie expenditure Inadequate diet-poverty Poor parenting skills (lack of knowledge of sufficient diet/ feeding technique) Child/ Parent interaction problems Food refusal Parental mental health/ cognitive problems Child abuse/ neglect Etiology Emotional deprivation Family dysfunction: marital stress, mental illness, substance abuse, spousal abuse, Infant comorbidities Unintentional GOLDEN RULE :Comprehensive History and Physical Exam Prenatal events : Medical complications of pregnancy, IUGR Alcohol, smoking Mother’s emotional reaction to the pregnancy. Birth history and nursery course Details of breast/ formula feeding Typical feeding schedule, plus food preparation (formula prep, portion size) Methods of feeding, length of time spent feeding, and diet supplementation/medication Description of type of solid foods taken (quantitative composition and frequency of meals and snacks) Prospective 3-day food diary A direct observation- issues of sucking ability, choking, regurgitation, vomiting, and diarrhea, mother’s affect and attitude. Change in formula, change from breast milk to formula, and changes in the primary individuals responsible for feeding the child Parents’ attitude about feeding (restrictions of food based on finances, religion Medical history and review of systems may reveal existing or undiagnosed conditions Spitting/vomitting/food refusal Diarrhea/fatty stools Snoring/mouth breathing/enlarged tonsils Recurrent wheezing/pneumonias Recurrent infections Travel to/ from developing countries Family composition Growth and eating pattern Any major events in the of other siblings child’s life Family stressors Chronic Illness, Young parental age Martial stress Single parenthood Affluent circumstances or Depression parents engaged in career Domestic violence development Substance abuse, Child rearing beliefs Employment / financial obligations. Family history stature and growth patterns Medical problems Genetic diseases Developmental delays Developmental History of the child Measure head circumference, weight, and length Analyze previous growth curves loss of subcutaneous fat &muscle mass wasted buttocks Untreated impetigo Edema /ascites Uncut/dirty Thin extremities fingernails Hepatomegaly Delays in social and Heart murmur speech Skin changes development Signs of vitamin Lack of eye contact deficiency Expressionless face Hair changes Hypotonia Mostly inconclusive Guided by history and physical exam CBC (Anemia) BMP with Mg (RTA/ metabolic disorders) U/A (Renal / Metabolic ) Lead level TFT ESR/CRP (sign of inflammation/infection Stool - fat, pH, reducing Skeletal survey in < 2yr substances, occult blood, old with ? Physical ova and parasites, abuse sweat chloride, Urine –organic and TB and HIV amino acids Celiac Panel Bone age (familial short Food allergy stature vs assessment endocrine/nutritional ) Organic FTT : Determine and treat the underlying cause Non-organic FTT : Hospitalize Sustained catch up growth (>30g/day ) Educate parents Multidisciplinary approach (Nutritionist, social worker, pediatrician) ACS. Monitor I/O’s, Daily weight Monitor feeding technique Age appropriate 150 Kcal/Kg (ideal wt) per 24hr Fortify the formula High calorie foods (peanut butter, whole milk, dried foods) Adding iron and Vitamin D , zinc Family centered approach Reinforce positive behavior Solid foods should be offered before liquids Minimize environmental distractions High calorie supplementation –Duocal,Polycose, Carnation Instant Breakfast, Formulas > 20cal/oz (Pediasure, Ensure, Resource) Observation during non feeding times : level of nurturing and responsiveness of the parent degree to which the child seeks the parent in times of need, amount of time parent cuddles/holds baby Severe malnutrition hypothermia, Bradycardia /hypotension Further diagnostic/ lab workup If abuse or neglect is suspected Lack of catch-up growth following outpatient management. Evaluating parent-child feeding interaction . FTT in 1st yr- ominous 1/3 with psychosocial FTT – developmental delay, social , emotional problems Organic FTT- variable, depends on cause and severity of FTT Need ongoing monitoring of cognitive and emotional development Summary FTT is a common sign which poses diagnostic and therapeutic challenge to pediatricians. Monitor growth patterns of children Good history and physical exam are the key for diagnosis Address both organic and nonorganic causes for any child with FTT Needs Multidisciplinary approach for management Behrman, R., et al. Nelson’s Texbook of Pediatrics. 14th edition Schecter, M, MD, Adam, H, “Weight Loss and Failure to Thrive.” Peds in Review. July 2000; 21(7) 238-239 Schwartz, I., MD. “Failure to Thrive: An old Nemesis in the New Milennium.” Pediatrics in Review. August 2000; 21(8) 257-264 Zenel, J, MD. “Failure to Thrive: A General Pediatrician’s Perspective.” Pediatrics in Review. November 1997; 18(11) 371- 378. Block, Nancy, Committee on Child Abuse and Neglect and the Committee on Nutrition. “ Failure To Thrive as a Manifestation of Child neglect” PEDIATRICS Vol. 116 No. 5 November 2005, pp. 1234-1237 Ficicioglu.C, Christina.K, MD. “Failure to Thrive: When to Suspect Inborn Errors of Metabolism”. PEDIATRICS Vol. 124 No. 3 September 2009, pp. 972-979 You are working in the emergency department when a mother brings in her 8-month-old son. She is concerned because he has had diarrhea for 2 months that has worsened over the last day. She explains that the stool is greasy, but there is no blood. He has had two episodes of sinusitis but no hospitalizations. They are new to town and he has not seen a physician since his 2-month health supervision visit. On physical examination, the boy appears pale, cachectic, and mildly dehydrated but alert. He has nasal congestion, his lungs are clear, and findings on his abdominal examination are normal. His weight is below the 5th percentile, length is at the 10th percentile, and head circumference is at the 25th percentile. He has a foul- smelling, greasy stool in his diaper. Of the following, the test MOST likely to reveal the diagnosis is A. enzyme-linked immunosorbent assay for Giardia B. serology for antigliadin antibodies C. stool evaluation for alpha-1-antitrypsin D. stool evaluation for ova, cysts, and parasites E. sweat test Thank You !!