Transcript Failure to Thrive - Serving the Underserved

FAILURE TO THRIVE
By
William Bithoney
Patrick Casey
Robert Karp
SUS
SUS
Failure to Thrive
Abnormal weight status during infanttoddler years
and/or
Abnormal weight gain
(weight growth velocity)
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Abnormal weight status
Referenced against:
• Genetic growth expectations for family
• Children of same gender and gestation
adjusted age
– <5% on NCHS curves
• Child's own length
– <10-25% on NCHS curves
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Abnormal weight gain
(Growth Velocity)
• Falling across two standard
deviation percentile lines on
NCHS curves over 6 month
period
• For at least one to two months
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FTT Definition includes:
"light"
"thin"
atypical weight gain
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Cautions Regarding Definition
of Failure-to-Thrive
• Genetically small due to parents size
• Children born small for gestational
age (SGA) may never catch up
• If born larger than long-term genetic
potential demonstrate decreased
growth rate in first 2 years
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FTT Definition:
Growth Only
• Not necessarily associated with
developmental/emotional
problems in child
• Not necessarily environmental
causation
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What's in a name?
Growth Delay
Growth Failure
Failure to Grow
Growth Deficiency
Failure to Gain Weight
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FTT of long duration
(Grown Older)
STUNTED:
• Abnormal length and head
circumference
• Psychosocial Dwarf?
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Failure-to -thrive Cause:
All children with Failure-To Thrive
are
Undernourished
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Three Methods to Categorize
Undernutrition in Children
Degree of
UnderNutrition
Gomez:
% median
weightfor age
Waterlow:
% median
weightfor-height
McLaren,
Read:
% median
wt/ht
for age ratios
None
Mild
Moderate
Severe
>90
75-90
60-74
<60
>90
80-90
70-79
<70
>90
85-90
75-84
<75
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Categorization of Undernutrition in 258
Children Referred for "Failure to Thrive"
Degree of
UnderNutrition
Gomez
Waterlow
McLaren,
Read
No. %
No. %
No. %
None
Mild
Moderate
Severe
5
132
112
9
64
149
42
3
18
38
156
46
2
51
43
4
25
58
16
1
7
15
60
18
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Clinical Subtypes
I. Medical Cause
– Organic vs. Non-organic vs. Mixed
II. Clinical Presentation
– Age of onset
– Severity
– Chronicity
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• Organic Etiology:
– medical disease present and clinically judged to
be sole cause of FTT
• Non-organic Etiology:
– problems in the child's environment judged to
be the primary cause of FTT, in the presense or
absence of medical disease
• MIXED Etiology:
– medical problem and problems in environment
in combination are judged to be cause of FTT
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Problems with Organic/NonOrganic Dichotomy
1. It is often difficult to place a child
in either category
2. The dichotomy fails to account for
the compounding effect of problems
in both the child and the
environment
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Problems with Organic/NonOrganic Dichotomy (Cont'd)
• 3. Children with either may have
symptoms like diarrhea or vomiting
• 4. Children with either may gain
weight while in the hospital
• 5. Global terminology is not specific
enough to develop an individualized
management plan
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Clinical Subtypes (Cont'd)
III. Socioemotional
0-3 months
Homeostasis
4-10 months
Attachment disorder
11-36 months
Separation
individuation disorder
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Clinical Subtypes (Cont'd)
IV. Psychiatric Diagnoses
Feeding Disorder
Depression
Reactive Attachment Disorder
V. Mechanical Feeding Disorder
Food Avesion
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Transactional FTT
Multiple aspects (overt or subtle)
of child, parents, and the
proximal and distal
environments interact across
time to result in FTT.
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Final Diagnosis of 131 Cases of
Failure to Thrive
Non-organic
Number
59
Percent
45
Interactional
46
35
Organic
22
16.7
Unknown
4
3.3
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Frequency of Organic Systems
Causing Failure to Thrive
Gastrointestinal
Most Common
Neurological
Respiratory-Pulmonary
Cardiovascular
Endocrine
Least Common
Other
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Prevalence of Failure to Thrive
• 3.5% of admissions to children's
hospitals
• 10% of clinic visists in urban and
rural outpatient settings
• up to 16% 0-4 year olds in low
income populations are "stunted"
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Failure to Thrive
• Weight is abnormally 2 standard
deviations below the mean for
gestation corrected age -- and/or
• weight crossess percentile curves by
two standard deviations
• weight to height ratio is depressed
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"My baby is just
small for her age"
-Parent
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Failure to Thrive:
Spectrum of Causes
Problem in
the Child
ORGANIC
Problem
in
the
Interactive
Environment
Effects
NON-ORGANIC
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Parent Functioning
Child Outcomes
•Development
•Learning
•Behavior
•Growth
•Health
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Goals of Clinical Evaluation
Identify conditions which:
1. Negatively affect growth potential
(disease)
2. Increase basic caloric needs (e.g. chronic
infection)
3. Decrease availability/utilization of
calories (e.g., malabsorption)
4. Negatively affect parents ability to meet
nutritional needs (can't/won't eat)
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Diagnostic Evaluation
1. Growth assessment
– confirm the diagnosis with weight and
height, present and past
2. History
– predisposing factors
3. Physical examination
– significant findings other than
malnutrition
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Diagnostic Evaluation (Cont'd)
• 4. Development-Behavioral
Assessment
– Assess delays in cognitive, language, or
motor functioning
– Identify any behavioral abnormalities
• 5. Laboratory Evaluation
– Varies for each child
– Stepwise approach is recommended
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Laboratory Evaluation
• Should be directed by findings from
the history and physical examination
• Document nutritional status:
– albumin, iron, zinc
• Child may have endemic problem:
– Tbc, AIDS, giardia
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Diagnostic Evaluation (Cont'd)
• 6. Nutritional and Feeding
Evaluation
– Content and structure of mealtimes
– Feeding techniques
• 7. Social History
– Identify parental/family strengths and
weaknesses
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Diagnostic Evaluation (Cont'd)
• 8. Parent/Child Interaction
– Especially as it relates to feeding
• 9. Psychiatric Evaluation
– Important if the caregivers emotional
state is adversely affecting parent-child
interaction
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Hospitalization vs. Outpatient Care
• Advantages of hospitalization:
– Able to observe and control feeding
– Able to observe the parent-child interaction
– Medical evaluation can be done easily
• Disadvantages of hospitalization:
– Cost
– Child (and parent) are away from their
normal environment
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Indications for Hospitalization of
Children with Failure-to-Thrive
1. Evidence of physical abuse
2. Extreme failure to thrive (starvation)
3. Extremely dysfunctional parent-child
relationship or family
4. When distance and transportation issues
mean outpatient management is not
practical
5. When outpatient management has failed
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Management of the Child with
Failure-to-Thrive
1.
2.
3.
4.
Nutritional asessment and intervention
Improved parent-child interaction
Developmental stimulation
Treatment/management of medical
conditions
5. Support and intervention for social and
family problems
6. Mental health referrals where indicated
7. Regular follow-up care
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Best Predictors of
Prognosis
• Age of onset, chronicity
• Ongoing quality of the home
environment
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Interactional Model of Failure-toThrive
PARENT
CHILD
•Economic Status
•Health
•Knowledge
•Emotional State
•Past Experience
•Appearance
•Health
•Neuro developmental
maturity
•Ease of Caregiving
Parent-Child Interaction
Failure-to-Thrive
Endocrine-Cellular
Dysfunction
Nutritional
Deficiency
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Environmental Characteristics:
Supports and Stressors
• Home
–
–
–
–
–
-Marital Relationship
-Physical Quality
-Organization
-Stability
-Economic Resources
• Family
• Neighborhood and Work
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