Transcript Failure To Thrive

Normal Growth Patterns
 Definitions
 Classification of FTT
 Etiology
 History
 Physical Exam
 Lab work
 Treatment
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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.
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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
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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
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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
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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.
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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.
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2. A child younger than 2 years of age with weight is less than
80% of the ideal weight for age.
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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.
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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
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Historically : Organic and Nonorganic
 Organic FTT: underling major disease process
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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.
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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
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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.
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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.
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Genetic/Metabolic/
Chromosomal disorders
Inborn errors of metabolism
Congenital syndromes
Sickle cell disease
Fetal alcohol syndrome
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Respiratory
 Obstructive: Tonsillar
hypertrophy, OSA
CF
Asthma
BPD
Chronic resp failure
 Infectious Disease
TORCH
Chronic infections
Parasitic infections
TB/HIV
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CNS
CP
Hypothalamic /CNS
tumors
Neuromuscular disorders
Lead toxicity
Cardiac
CHF
Cyanotic heart disease
Vascular rings
 Renal
UTI/ Chronic
pyelonephritis
RTA
Renal Failure
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Endocrine
Hypothyroidism/Hyperthy
ro
Diabetes
Rickets
Growth hormone
deficiency
Adrenal insufficiency
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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
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Inadequate calorie intake
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Inadequate calorie absorption
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Excessive calorie expenditure
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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
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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
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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
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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
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Family composition
 Any major events in the
child’s life
 Family stressors
Chronic Illness,
Martial stress
Single parenthood
Depression
Domestic violence
Substance abuse,
Employment / financial
obligations.
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Growth and eating pattern
of other siblings
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Young parental age
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Affluent circumstances or
parents engaged in career
development
Child rearing beliefs
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Family history
stature and growth patterns
Medical problems
Genetic diseases
Developmental delays
Developmental History of the child
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Measure head
circumference, weight, and
length
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Analyze previous growth
curves
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loss of subcutaneous fat
&muscle mass
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wasted buttocks
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Untreated impetigo
Uncut/dirty
fingernails
Delays in social and
speech
development
Lack of eye contact
Expressionless face
Hypotonia
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Edema /ascites
Thin extremities
Hepatomegaly
Heart murmur
Skin changes
Signs of vitamin
deficiency
Hair changes
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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
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Stool - fat, pH, reducing
substances, occult blood,
ova and parasites,
 sweat chloride,
 TB and HIV
 Celiac Panel
 Bone age (familial short
stature vs
endocrine/nutritional )
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Skeletal survey in < 2yr
old with ? Physical
abuse
 Urine –organic and
amino acids
 Food allergy
assessment
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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)
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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)
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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
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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
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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
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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
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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) 371378.
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
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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 foulsmelling, 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
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Thank You !!