Failure to thrive pdf - د.فاضل

When Simple and Natural

Gets Complicated

Failure to Thrive

Definition

•  Failure to Thrive (FTT):
•  Sign that describe a particular problem rather

than diagnosis which is failure to gain weight

in childhood.

–  Weight below the 5

percentile for age and sex

–  Weight for age curve falls across two major

percentile lines

–  weight gain is less than expected

•  Other definitions exist, but are not superior in

predicting problems or long term outcomes

Foster

placement

7/1/11

Introduction

•

  Specific infant populations:

–

Premature/IUGR – wt may be less than 5

percentile, but if following the growth curve
and normal interval growth then FTT should
not be diagnosed

Major Anthropologic Categories of FTT.

WEIGHT

HEIGHT

TYPE I

NOR

Malnutrition of organic or non-
organic etiology

TYPE II

NOR

Endocrine, bony dystrophy,
Constitutional short stature

TYPE III

Chromosomal, metabolic,
severe malnutrition

HC: Head Circumference
NORM: Normal

ETIOLOGY

•  2 BIG categorize but large differential pool.

ORGANIC

INORGANIC

MIXED

Causes of Failure to Thrive

Inadequate

Input

Excessive

Output

Increased

Utilization

CLASSIFICATION

More useful classification system is

Malnutrition

FTT

Inadequate

Caloric Intake

Malabsorption

Excessive

Caloric

Expenditure

FAILURE TO THRIVE

Psychosocial
Nutritional
Kwashiorkor
Marasmus

Zinc/iron deficiency

Feeding disorders

Oral-motor apraxia

Cleft palate
Dentitions

GI
Vomiting

Gastroesophageal reflux
Structural anomalies

Central nervous system lesion

Diarrhea

Chronic toddler diarrhea

Infectious

Malabsorption

Celiac disease
Inflammatory bowel disease
Hepatic
Chronic hepatitis
Glycogen storage diease
Infectious
Tuberculosis

Human immunodeficiency virus

Cardiac

Pulmonary
Tonsillar hypertrophy

Cystic Fibrosis

Renal

Chronic pyelonephritis
Fanconi syndrome (and variants)

Chronic renal insufficiency

Endocrine
Hypothyroidism

Rickets

Viitamin D deficiency

Vitamin D resistance

Central nervous system lesion

Hypophosphatemic

Growth hormone deficiency/resistance
Growth hormone deficiency/resistance
Hypercortisolism

Pseudohypoparathyroidism

Type I diabetes mellitus (poorly controlled,
Mauriac syndrome)

Central nervous system
Pituitary insufficiency

Diencephalic syndrome

Other chronic diseases

Oncologic

Calories, Calories,……

• Root of growth failure stems from
•  inadequate calories
•  – Inadequate intake
•  – Increased demands
•  – Poor absorption
•  Infants require approximately
110-120 kcal/kg/day
At age 1 year, 100 kcal/kg/day

CALORIC INTAKE

•  Inadequate Caloric Intake

–  Incorrect preparation of formula
–  Poor feeding habits (ex: too much

juice)

–  Poverty
–  Mechanical feeding difficulties

(reflux, cleft palate, oro-motor
dysfunction)

–  Neglect

Consider child abuse and

neglect in cases of

FTT that don t respond to appropriate
interventions

Inadequate absorption

– Celiac disease
– Cystic fibrosis
– Milk allergy
– Vitamin deficiency
– Biliary Atresia
– Necrotizing enterocolitis

Increased metabolism

– Hyperthyroidism
– Chronic infection
– Congenital heart disease
– Chronic lung disease

•  Other considerations

– Genetic abnormalities, congenital infections,

metabolic disorders (storage diseases, amino
acid disorders)

COMPREHENSIVE NUTRITIONAL

ASSESMENT

•  Dietary history
•  Medical and medication history
•  Physical examination
•  Growth and anthropremetric measurements
•  Laboratory tests.

HISTORY

•  Pregnancy/Birth
LBW, IUGR, prematurity, postnatal complications, tube

feeding. Substance abuse? postpartum depression?

•  Dietary type of food, time spent over meal, number of

meals, self feed, formula/supplements, unusual feeding

behavior, who feeds?

•  Past medical history
Illnesses, hospitalizations, reflux, vomiting, stools, difficulty

swallowing

•  Social
Who lives in the home, family stressors, poverty, drugs?
•  Family
Parental height, siblings, Medical condition (or FTT) in

siblings, mental illness, stature?

DIETARY HISTORY

•  Assess methods of feeding
•  breastfeeding patterns (including maternal diet use

of medications that can affect milk production and

let-down such as alcohol or diuretics)

•  formula preparation
•  volume consumed
•  feeding techniques.
•  Caloric counts- food diary
•  A detailed history of formula preparation :may

reveal a dilute formula that contains insufficient

calories and excess water.

Dietary Associations With Poor

Growth in Young Children

– Breastfeeding difficulties
– Improper formula mixing
– Poor transition to food (6 to 12 months of

age)

– Excessive juice consumption
– Avoidance of high-calorie foods

EVALUATION

•  Accurately plotting growth charts at every

visit.

•  Use correct growth charts!
•  Evaluate the trends
•  History and Physical more important than

labs

Examination: Key Points

•  Infant eye contact (if avoids may be abuse)
•  Poor suck or motor skills
•  Watch caretaker feed the infant!!!
•  Plot height, weight and head circumference
•  Dysmorphic features
•  Lung or heart exam
•  Skin: scars, jaundice, eczema, bruises or rash

Failure To Thrive

This child has

Celiac Syndrome.

It is an intestinal

mal-absorption

syndrome.

7/1/11

Failure to Thrive

7/1/11

Failure to Thrive

7/1/11

Foster

placement

7/1/11

Failure To Thrive

7/1/11

INVESTIGATIONS

•  Lab tests should be guided by H&P.
•  Less than 2% of the lab studies performed

in evaluating children with FTT were
useful.

Sills RH AM J Dis Child 1978

INVESTIGATIONS

HISTORY AND

PHYSICAL

FIRST LINE
CBC
ESR, CRP
UA/Cx,
Cr, glucose,
Ca
Thyroid
functions
Sweat Chloride
Celiac serology
(age)

SECOND LINE
Serum AA
Lead level
Ur organic acids
LFTs
PPD
Abd US
CXR
Head US
EKG/Eho

HISTORY AND PHYSICAL

EXAMINATION

Organic Cause

Cause Not

Obvious

Feeding

Disorder

Behavioral

Psychosocial

Etiology

Investigatio

and

Managemen

Indicated

Laboratory Screening

Tests

Positive

Negative

Treatment Malnutrition

and

Multidisciplinary

Services

INFANT WHO HAS FTT

MANAGEMENT

•  Goal is catch-up weight gain
•  Most cases can be managed with nutrition

intervention and/or feeding behavior modification

•  General principles:

–  High Calorie Diet
–  Close Follow-up

•  Keep a prospective feeding diary-72 hour

CALORIC REQUIREMENT

•  Stabilization phase (1-7 days):
1-Rehydaration
2-treatment of infection
3- F75

•  Rehabilitation phase(2-6 weeks)
1- Treatment of infection
2-F100

•  Ready to use therapeutic foods.

INTAKE

•  Energy intake should be 50% greater than

the basal caloric requirement

•  Concentrate formula, add rice cereal to pureed

foods

•  Add taste pleasing fats to diet (cheese, peanut

butter, ice cream)

•  High calorie milk drinks (e.g Pediasure has 30 cal/

oz vs 19 cal per oz in whole milk)

•  Multivitamin with iron and zinc
•  Limit fruit juice to 8-12 oz per day

Vitamin and Mineral Supplementation

• ZINC

– No reliable lab assessment
– Baseline addition

• IRON

– If Hemoglobin, Hematocrit or MCV labs indicate
further work up add to diet ( After phases Interfere with
host defense mechanism)

Medical Appetite Stimulation

Cyprohepatidine has no proven

long-term benefit

Lemons PK, Dodge NN. Persistent failure-to-thrive: a case study. J Pediatr

Health Care 1998; 12: 27.

Refeeding Syndrome

• Sweatiness
• Hyperthermia
• Hepatomegaly – increased glycogen

deposition

• Widening of the cranial sutures- brain

growth faster than the skull

• Increased periods of sleep
• Fidgetiness or hyperactivity

Refeeding Syndrome

• Follow Potassium and Phosphorus

in the acute period of
reinstating nutrition

• Initial intracellular ion shifts my

cause

–

Hypokalemia

–

Hypophosphotemia

• Can produce serious arrhythmias

and muscle weakness

WHEN TO HOSPITILIZE

•  Do you hospitalize?

– Rarely necessary
– Consider if:

•  the child has failed output management
•  FTT is severe

–  Medical emergency if wt <60-70% of ideal wt
–  Hypothermia, bradycardia, hypotension

•  safety is a concern

HOSPITILIZATION

•  For difficult cases:

– Multidisciplinary team approach produces

better outcomes

•  Dietitians
•  Social workers
•  Occupational therapists
•  Psychologists

– NG tube supplementation may be necessary

DIAGNOSED WITH CELIAC DISEASE

AND GLUTEN FREE DIET STARTED

THANK YOU