Failure To Thrive

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					 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 !!

				
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