Transcript “Failure to Thrive”

“Failure to Thrive”
Suzanne Swanson Mendez, MD
August 31, 2012
Defining FTT
• “Growth Deficiency”
• Crossing 2 major
percentile lines or a term
child less than 5th
percentile on growth chart
• A child under 6 months
who has not grown for 2
months
• A child over 6 months
has not grown for 3
months
•
http://www.mashby.com/images/posts/skinny_ki
d.gif
Types of Growth Deficiency
Type Growth Chart
Findings
Etiology
1
WEIGHT decreased more
than height, Normal head
circumference (OFC).
Most common. From inadequate
intake, inadequate absorption,
increased metabolism, or
defective utilization of calories.
2
WEIGHT AND HEIGHT
Familial short stature,
both decreased
endocrinopathies, constitutional
proportionally, normal OFC. growth delay, skeletal dysplasias.
3
WEIGHT, HEIGHT, OFC all
decreased versus normal.
CNS abnormalities,
chromosomal defects, in
utero/perinatal insults.
Type 1A: Inadequate intake
• Incorrect preparation of formula: too dilute or too
concentrated
• Breastfeeding difficulties
• Unsuitable feeding habits for age: excessive juices,
food fads, poor transition to food (6-12 months)
• Behavioral problems affecting eating
• Poverty and food shortages
• Disturbed parent-child relationship: neglect or
hypervigiliance
• Mechanical feeding difficulties: oromotor dysfunction,
congenital anomalies, severe reflux, CNS damage
Type 1B: Inadequate absorption
of calories
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•
•
•
Celiac disease
Cystic fibrosis
Cow’s milk protein allergy
Vitamin or mineral deficiencies (acrodermatitis
enteropathica, scurvy)
• Biliary atresia or liver disease
• Short gut syndrome
Type 1C: Increased metabolism
• Hyperthyroidism
• Hypoxemia
 Chronic lung disease
 Congenital heart defect
 Severe obstructive sleep apnea
• Chronic disease
 HIV/Immunodeficiency
 Renal disease
 Malignancy
Type 1D: Defective utilization of
calories
• Genetic abnormalities
(Trisomy 13, 18, 21)
• Congenital infections
• Metabolic disorders
(storage diseases, amino acid
disorders)
Case One
• CJ, an 8-month-old male presents for WCC
• Last seen at 6 months with poor weight gain,
increased calorie formula recommended
• Plotting his weight, you notice that he has
crossed from the 95th percentile (at 2 months of
age) to the 5th percentile now
• What would you do?
Workup
• History and physical will identify etiology in most
cases
• What do you want to know?
• Pregnancy/birth history:
 IUGR, congenital infections, risk factors for HIV,
prenatal care and labs
 Gestational age at birth, size at birth (SGA?)
 Newborn screen
 What does the newborn screen include in D.C.?
 When is it done?
History and Physical
• Diet/Feeding history:
 How much does the baby eat? How is formula mixed?
(What? When? Where? With whom? How?)
 Food battles
•
•
•
•
Stooling/Voiding patterns
Vomiting or signs of reflux after feeds?
PMH: Hospitalizations, Recurrent infections?
Growth curve: growth velocity is most important and can point
out when failure began.
• Medications/Herbs/Supplements
More History
• Allergies
• Environmental and Toxin
Exposures
• Social History: risks for
feeding problems
• Family History: includes
parental heights
• Developmental History
• Review of Systems
Expected Feeding and Voiding
Patterns
Age
Feeds
Calories
Required
Voids/Stools
Neonate
8-12
feeds/day;
5.5oz/kg/d
100-110 kcal/kg/d
6-8 wet diapers, at
least 2 stools/day
2-4 months
6-8 feeds;
90-100 kcal/kg/d
>3-4 wet diapers,
stool freq varies
70-90 kcal/kg/d
varies
18-24oz/day
5-12 months
24-32oz/day
plus solids
>5 years
3 meals, 2
snacks
1500 kcal (for first 20 varies
kg) + 25 kcal for each
additional kg
Signs of successful
breastfeeding
1) Weight gain; no more than 10% loss from BW in 1st week
2) Baby calm, relaxed after feed; no more hunger cues
3) Feeds 8-12 times/day
4) Swallowing may be heard
5) Steady rhythmic motion in cheeks
6) >6 soaking wet (or heavy) diapers/day
7) Stools change to yellow by 7th day of life, at least 1-2
stools/day until 5-6 weeks of age
8) Breasts feel softer/emptier after feed
• At 4-6 weeks, may pull away if flow decreases---> compress
to increase flow; not a sign of less milk
Further workup of Growth
Deficiency
• From the mother in Case One:
• Prenatal/birth history: Had regular prenatal care, prenatal
labs normal, HIV negative; Born by NSVD at 39 wks,
home with mom on DOL 2. NB screen normal.
• Nutrition/Feeding history:
 For first 2 months, breastfed only and did well (95th%)
 Then started refusing to eat, breastfed at night only for 5 min
q2hrs. Often vomited during feedings when upset.
 Started on 24kcal formula during day at 6 months by pediatrician
due to poor wt gain but often refused to drink.
 Does not seem to like any pureed foods: turns head away.
Feeding and Voiding
• Feeding history: No difficulties with swallowing,
no diaphoresis or tiring with feeds, but vomiting
has become a daily event--mom blames his
“temper”
• Voiding/stooling patterns:
 3 wet diapers/day;
 Stools every 3-4 days
 No steatorrhea or blood/mucus noted in stools
 Stools are yellow to green and soft, usually large
amounts
Constipation
• Is this baby constipated?
• Infrequent stooling does not necessarily mean
constipation nor does straining
• Worry about constipation if:
 Pain or crying during passage of BM
 Unable to pass BM after straining/pushing over 10
minutes
 No BM after more than 3 days (except if breastfed and
over 1 month--may have 5-6 days btwn stools)
How much does this baby
weigh?
For an estimate of average for
age:
Newborn: 3.2 kg
Ages 3-12 months
[for weight in kg]:
Age (in months) + 9
2
But in an emergency, use the
color-coded tape!
The First Year
• Baby should regain BW by 2 weeks (earlier if
formula fed)
• Doubles BW by 4-5 months
• Triples BW by 1 year, quadruples by 2
• Height does not double until 3-4 years
• OFC reflects neuronal cell division from 0-6
months; later from neuronal cell growth and
supporting tissue proliferation
Expected Growth
Age
DAILY weight
gain
Height
Increase
OFC
increase
0-3 months
20-30 grams
3.5cm/month
2 cm/month
3-6 months
15-20 grams
2 cm/month
1 cm/month
6-9 months
10-15 grams
1.5cm/month
0.5 cm/mon
1.2cm/month
0.5cm/mon
9-12 months 8-12 grams
Growth history
• BW 3.4kg (at 39 wks)
• 6.8 kg at 2 months
(95th percentile)
• 7 kg at 6 months (10th
percentile)
• 7.1 kg at 8 months (5th
percentile)
• Height/OFC both near
50th percentile
•
http://www.keepkidshealthy.com/growthcharts/b
oysbirth.gif
History (continued)
• PMH/PSH: No hospitalizations or surgeries, no
recurrent infections, no risk factors for HIV, NB screen in
Virginia was normal, AOM at 6 months.
• Medications: none, no herbs, no supplements
• Allergies: no known drug allergies, no known
food allergies
• ROS: no snoring/apnea noted, but not a good
sleeper and mom thinks he cries a lot. No
tachypnea, no choking or diaphoresis during
feeds; otherwise unremarkable.
More History:
• Developmentally, he “cruises” and says “mama” and
“dada,” but has quite a temper according to mom.
• Family history: mid-parental height is at 50th percentile
(dad’s + mom’s height in cm +/- 13) div by 2
• Social history:
 Father works as engineer, moved from China 2 years ago
 First child; lives only with mom and dad now, but grandmother
lived with family for child’s first 2 months then returned to Taiwan
 Mom’s English skills very limited
Screening for social factors
• No longer “organic” versus “nonorganic” FTT;
many cases multifactorial
• Caregiver depression/attachment disorder: can
affect baby’s growth especially in the first 6 months
• Anxiety disorder or separation/ individuation
disorder: may affect baby’s growth from 6-12 months
• Child abuse or neglect always a concern
Maternal depression
• One of the most common complications of pregnancy
• 10-20% of women experience depression during or
within the first 12 months after pregnancy
• Pediatrician often has more contact with mothers than
their PCPs do yet less than 10% screen
• 2 easy questions:
 During the past month, have you been bothered by
feeling down, depressed, or hopeless?
 During the past month, have you been bothered by
having little interest or pleasure in doing things?
*Parents might respond better to paper questionnaire
Further social history
• CJ’s mom does admit
to feeling very
isolated and screens
+ for anhedonia
• Does not drive and is
alone with infant in
apartment all day
• Nearest friends 30
miles away
Physical Exam
• Physical exam: weight 7.1kg (5th percentile),
height 69 cm (25th percentile), OFC 45 cm
(50th percentile)
• Fussy but consolable
• Observed feeding: Mom offers bottle but
baby gets irritable, refuses. Mom very
anxious.
• Description of formula mixing correct
• Physical exam otherwise unremarkable
Nutrition
* A prospective 3-day diet record is helpful in most
cases of growth deficiency
* In this case, baby refusing feeds and vomiting
when upset were interfering with adequate
caloric intake
Types of Growth Deficiency
Type Growth Chart
Findings
Etiology
1
WEIGHT decreased more
than height, Normal head
circumference (OFC).
Most common. From inadequate
intake, inadequate absorption,
increased metabolism, or
defective utilization of calories.
2
WEIGHT AND HEIGHT
Familial short stature,
both decreased
endocrinopathies, constitutional
proportionally, normal OFC. growth delay, skeletal dysplasias.
3
WEIGHT, HEIGHT, OFC all
decreased versus normal.
CNS abnormalities,
chromosomal defects, in
utero/perinatal insults.
Labs for Case One
•
•
•
•
Screening Hb, Pb levels normal for age
Confirm NB screen results
Other labs should be guided by detailed H&P
In CJ’s case, physical was unrevealing and
history + observation suggests parent-child
interaction problem
• Later pH probe negative for GERD
Management
• Depends on underlying
cause
• For CJ, counseling for
mother was
recommended
• Increased social support
• Vomiting improved with
behavioral management,
less force-feeding and
decreased parental
anxiety.
Case Two
• AB, a 12-month-old infant, presents to Urgent
Care for fever, ear pain
• T 38 C, HR 130, RR 24, sat 100% RA
• Wt 7.1 kg (at 3rd percentile for age)
• History of fever for 2 days with cough for 1 wk
• Mom also reports baby has had loose stools for
“months” but no vomiting.
 Stools are yellow to green without blood or mucus;
occur 3-4 times/day.
• Normal urine output with light yellow urine.
• What else do you want to know?
History
• PMH/PSH: Born at term, no problems with
pregnancy, NB screen negative. BW 3.8kg.
Multiple episodes of AOM, last 1 month ago.
Also hospitalized 1x for bronchiolitis and once
for pneumonia, no surgeries.
• Medications: High-dose amox completed 2 1/2
weeks ago
• Allergies: NKDA, no known food allergies
• Family history: Mid-parental height at 75th%,
mom has Type I diabetes
Further history
• No growth chart available, but mom thinks child
hasn’t gained wt in months: “much smaller than
other kids her age.”
• Nutrition history: breastfed until 2 months and
then switched to formula and did well. At 4
months, rice cereal introduced, then pureed
foods at 6 months. Now eats “everything”--all
table foods.
Social and developmental
history
• Developmentally appropriate: sat at 6 months,
first words at 8 months, now can walk with both
hands held
• Social history:
 Parents separated 7 months ago; father no longer
involved
 Mom works part-time; estimates income at
$20,000/year
 Has neighbors who cares for child while she works
 History of depression; denies feeling depressed
currently but is very worried about her daughter
What next for AB?
• More history?
• Physical exam: wt 7.1 kg (3rd%), L 70 cm (10th%),
and OFC 46 cm (50th%)
What do these parameters suggest about her growth
deficiency?
• Can be Type I (chronic malnutrition) or Type II
growth deficiency:
 Familial short stature/Constitutional growth delay
 Endocrinopathy
 Skeletal dysplasias
*Though her weight is still more affected than her height
Physical exam
• Child is thin, but alert, interactive, in no distress
• HEENT: Thin, wispy blonde hair; R TM reddened and
retracted, L TM with typmanosclerosis; Tonsils 2+, no
lymphadenopathy.
• Heart exam normal
• Lungs have transmitted upper airway sounds but good
aeration.
• Abdomen is soft but very full/ protuberant, no HSM
• Tanner I GU, good femoral pulses
• Extremities are thin but well-perfused; no signs of
dehydration, no edema
• Skin warm, pink, without rashes
Differential diagnosis?
• Type I Growth Deficiency:

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Inadequate caloric intake
Increased metabolism
Inadequate absorption
Defective utilization
• Type II Growth Deficiency: since height is also
affected (but still less so than weight)




Familial short stature
Constitutional growth delay
Skeletal dysplasias
Endocrinopathies
Workup
• You send her home with a prospective 3day food diary and Augmentin and a WIC
referral
• Encourage social support for mom
• 3 meals/3 snacks on a daily schedule for
child
• Any labs?
Labs
• CBC
for anemia, malignancy,
immunodeficiency
• Electrolytes and UA
for renal/metabolic disease
• Albumin and LFTs
for abdominal workup
• Stool studies:
wbc/rbc smear, O&P
• Sweat chloride test
• HIV, consider quantitative
immunoglobulins
Lab Results
• CBC shows normocytic
anemia
• Lytes, UA normal
• Albumin low at 2.3 mg/dl
• Stool studies negative for
wbc, rbc, O&P
• Sweat chloride normal
• HIV negative
• QuIg’s normal (including
IgA)
Follow-up
• Two weeks later, the child returns and mom
seems happier, but AB has only gained 0.05 kg
(about 3g/day)
• How much should she be gaining?
• Answer: about 8 g/day just for normal growth, not including catch-up
• Nutrition diary reveals an intake of 800 kcal/day
(about 85 kcal/kg of IDEAL body weight/day)--is
this enough?
• Answer: It might be enough for normal growth, but she will need
more to catch up (up to 1.5 x more)
Differential diagnosis now
• Type I growth deficiency:
 Inadequate intake? Not according to food diary
 Increased metabolism? Not HIV/renal disease,
unlikely malignancy or CHD/CLD
 Inadequate absorption? Could be celiac disease;
unlikely CF (sweat Cl normal) or vitamin def.
 Defective utilization? No signs of genetic
abnormalities, congenital infections, or metabolic
disorders
• Type II growth deficiency less likely without
family history, signs of endocrinopathy
Further work-up
• Given her low albumin with normal kcal
intake for age and chronic diarrhea,
malabsorption is likely
• Stool reducing subs/alpha-1-AT sent
• Screening test for celiac disease:
Anti-tissue transglutaminase Ab (IgA and IgG) also
sent
• TGA comes back +
Management
• AB is switched to a
gluten-free diet and starts
to gain weight well
• Small bowel biopsy
confirms diagnosis
• Height also improves
• Pt continues to do well
with close followup and
social situation improves
Importance of treating Growth
Deficiency
• Early childhood is a key period for growth and
development.
• Often multifactorial in etiology
• Children with “failure to thrive” are at risk for:
 Behavioral problems
 Developmental delay
 Short stature
• Prompt intervention and close follow-up needed
to reverse FTT pattern and prevent associated
problems
On the path to good health!
Bibliography
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Behrman RE, “The First Year,” Nelson Textbook of Pediatrics, Chapter 10, 17th
edition, 2004.
Brayden RM, Daley MF, Brown JM, “Ambulatory and Community Pediatrics: Growth
Deficiency,” Current Pediatric Diagnosis & Treatment, 16th edition, 2003, p 239-240.
Gahagan, Sheila, “Failure to Thrive: A Consequence of Undernutrition,” Pediatrics in
Review 2006;27:e1-e11.
Krebs NF, Hambidge KM, Primak LE, “Normal Childhood Nutrition & Its Disorders,”
Current Pediatric Diagnosis & Treatment, 16th edition, 2003, p. 277-307.
Krugman S and Dubowitz H, “Failure to Thrive,” American Family Physician, 68:5,
Sept. 2003.
LPCH Health Library: “Constipation.” Pediatric Housecall Online. Barton Schmidt,
Updated Aug. 2002.
http://www.lpch.org/HealthLibrary/ParentCareTopics/AbdomenGISymptoms/Constipat
ion.html
Robertson J, Shilkofski N, Johns Hopkins Hospital, “Normal Nutrition and Growth,”
Chapter 20, The Harriet Lane Handbook, 17th edition, August 2005.
Bibliography (continued)
• Save Babies Through Screening Foundation, “Disorders Screening
for in State NBS Programs and Puerto Rico,” Updated June 18,
2006. http://www.savebabies.org/states/washingtonDC.php
• “Food Stamp Program,” Food and Nutrtion Services Home Page,
Last updated October 11, 2006. http://www.fns.usda.gov/fsp/faqs.htm#2
• Flora, B, “Breastfeeding Essentials: Is My Baby Getting Enough?”
Last updated April 2003. http://breastfeeding.hypermart.net/enoughmilk.html
• Johnson CP and Blasco PA, “Infant Growth and Development,”
Pediatrics in Review. 18:7, July 1997.
•
“Women, Infants, and Children,” Food and Nutrition Service, USDA, Last
updated June 20, 2005.
http://www.fns.usda.gov/wic/
D.C. Newborn Screening
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1) 3-Methylcrotonyl-CoA carboxylase deficiency (3MCC)
2) 3-OH 3-CH3 glutaric aciduria (HMG)
3) Argininosuccinic acidemia (ASA)
4) Beta-Ketothiolase deficiency (BKT)
5) Biotinidase deficiency (BIOT)
6) Carnitine uptake defect (CUD)
7) Citrullinemia (CIT)
8) Classical galactosemia (GALT)
9) Congenital adrenal hyperplasia (21-hydroxylase deficiency)
(CAH)
10) Congenital hypothyroidism (CH)
11) Cystic fibrosis (CF)
12) Glutaric acidemia type I (GA 1)
13) Hb S/C disease (Hb S/C)
14) Hb S/ß-thalassemia (Hb S/ßTh)
15) Homocystinuria (due to CBS deficiency) (HCY)
16) Isovaleric acidemia (IVA)
17) Long-chain L-3-OH acyl-CoA dehydrogenase deficiency
(LCHADD)
18) Maple syrup disease (MSUD)
19) Medium-chain acyl-CoA dehydrogenase deficiency
(MCADD)
20) Methylmalonic acidemia (Cbl A,B) (Cbl A, B)
21) Methylmalonic acidemia (mutase deficiency) (MUT)
22) Multiple carboxylase deficiency (MCD)
23) Phenylketonuria (PKU)
24) Propionic acidemia (PROP)
25) Sickle cell anemia (Hb SS disease) Hb (SS)
26) Trifunctional protein deficiency (TFP)
27) Tyrosinemia type I (TYR I)
28) Very long-chain acyl-CoA dehydrogenase deficiency
(VLCADD)
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29) 2-Methyl 3-hydroxy butyric aciduria (2M3HBA)
30) 2-Methylbutyryl-CoA dehydrogenase deficiency (2MBG)
31) 3-Methylglutaconic aciduria (3MGA)
32) Argininemia (ARG)
33) Biopterin cofactor biosynthesis, defects of (BIOPT BS)
34) Biopterin cofactor regeneration, defects of (BIOPT REG)
35) Carnitine palmitoyltransferase I deficiency (liver) (CPT IA)
36) Carnitine palmitoyltransferase II deficiency (CPT II)
37) Carnitine: acylcarnitine translocase deficiency (CACT)
38) Citrullinemia type II (CIT II)
39) Dienoyl-CoA reductase deficiency (DE RED)
40) Galactokinase deficiency (GALK)
41) Galactose epimerase deficiency (GALE)
42) Glutaric acidemia Type II (GA 2)
43) Hypermethioninemia (MET)
44) Hyperphenylalaninemia, benign (H-PHE)
45) Isobutyryl-CoA dehydrogenase deficiency(IBG)
46) Malonic acidemia (MAL)
47) Medium/short-chain L-3-OH acyl-CoA dehydrogenase
deficiency (M/SCHADD)
48) Medium-chain ketoacyl-CoA thiolase deficiency (MCKAT)
49) Methylmalonic acidemia (Cbl C,D) (Cbl C,D)
50) Short-chain acyl-CoA dehydrogenase deficiency (SCADD)
51) Tyrosinemia type II (TYR II)
52) Tyrosinemia type III (TYR III)
53) Variant Hb-pathies (including HB E) (Var Hb)
Food insecurity
• What social programs
might help this
family?
 Food stamps
 WIC

http://www.singlesourcephoto.com/vermont/image
s/vt/vtc0072bg.jpg
Federal Poverty Guidelines
• Federal Poverty Guideline 2006: Annual income
of $16,600 or below for family of 3
• Food stamp program
 For families with gross income of 130% or below FPG
(net income 100% or less)
 All family members must provide a SSN or apply for
one
 Limited to US citizens except for many children,
elderly immigrants, those working in U.S. for a certain
amount of time
 Average monthly benefit $86/person; $200/household
WIC
• WIC (Women, Infants, and Children):
 Federal grant program
 Provides supplemental nutritious foods, nutrition
education, screening and referrals for
pregnant/breastfeeding women and children up to
age 5
 Gross income at or below 185% of FPG
($30,710 for a family of 3 for July 2006-June 2007)
 Serves 45% of all infants in the U.S.
 Nutrition risk requirement: Must be seen by a health
professional (may be in WIC clinc for free) and have
height/weight recorded and screen for anemia.