Failure to Thrive Dr Usha Mallinath Dr Richard Mones.

Failure to ThriveFailure to Thrive

Dr Usha Mallinath

Dr Richard Mones

DefinitionDefinition

Wt below 3 rd centile Wt drops 2 major centiles

Wt for length below 3 rd centile

Wt < 80% ideal wt for age

Historic classification

Historic classification

Organic: those for which there is a clear genetic,

medical, or anatomic etiology, a very large

differential Nonorganic:

insufficient emotional or physical

nurturing without pathophysiological abnormality

Calories, CaloriesCalories, Calories

Root of growth failure stems from

inadequate calories Inadequate intake Increased demands Poor absorption Infants require

approximately110-120 kcal/kg/day

At age 1 year, 100 kcal/kg/day

Normal Weight GainNormal Weight Gain

Age Mean Daily weight gain

0-3 m 26-31g

3-6 m 17-18g

6-9 m 12-13 g

9-12 m 9 g

1-3 yr 7-9g

4-6yr 6g

EpidemiologyEpidemiology

1-5% tertiary hospital referrals

5% in 2006 in USA , CDC High incidence poverty, low socio-economic status

50% not identified by health care professions

Non organic FTT common in females

PathogenesisPathogenesis

Insufficient food intake Increase Energy Requirement

Malabsorption

PathogenesisPathogenesis

Insufficient food intake

Inadequate amount of food provided or available

Structural causes of poor feeding e.g. cleft palate, Treacher-Collins

Anorexia of chronic disease

PathogenesisPathogenesis

Malabsorption /Steatorrhea

Celiac disease Chronic Liver disease Cystic Fibrosis Chronic diarrhea

PathogenesisPathogenesis

Increase Energy Requirement

HIV Congenital Heart disease Hyperthyroidism

Etiology system based

Etiology system based

GI RS CVS Renal ID Genetic Heme/Onc Endocrine

GI CausesGI Causes

Feeding disorders Diarrhea

Cleft palate Infectious

Dentition Malabsorption

oro-motor

Vomiting Hepatic Biliary atresia

GERD Chronic Hepatitis

Stricture Cirrhosis

PulmonaryPulmonary

CF BPD Tonsilar/ Adenoidal hypertrophy

EndocrineEndocrine

Hypothyroid Rickets DM GH deficiency Adrenal insufficiency

Cardiac CausesCardiac Causes

Congenital cardiac disease/CHF POOR INTAKE ? Increased metabolic demands Possible fluid restrictions Early interventions which may interfere with development of normal suck/swallow coordination

IDID

HIV TB Parasites

Heme/OncHeme/Onc

Classic B-symptoms include

weight loss anorexia

GeneticGenetic

Chromosomal abnormalities Trisomy 13, 18, 21 Deletion of chromosome 22 Gonadal dysgenesis (45,X), etc

Evaluate for dysmorphisms

RenalRenal

Renal Tubular Acidosis Disorder of HCO3 and H+ reabsorption in renal tubules

Urine pH >5.5 in light of systemic

acidosis

Diagnostic Classification of causes: inadequate Nutrition Intake

Diagnostic Classification of causes: inadequate Nutrition Intake Not enough food offered

–Food insecurity –Poor knowledge of child's needs

Poor transition to table food Avoidance of high-calorie foods

–Formula dilution –Excessive juice –Breastfeeding difficulties –Neglect

Child not taking enough food –Oromotor dysfunction –Developmental delay –Behavioral feeding problem

Altered oromotor sensitivity Pain and conditioned aversion

Emesis –Gastroesophageal reflux –Malrotation with intermittent volvulus –Increased intracranial pressure

MalabsorptionMalabsorption

Cystic fibrosis Celiac disease Food protein insensitivity or intolerance

Increase Metabolic demands

Increase Metabolic demands

Insulin resistance (eg, intrauterine growth restriction)

Congenital infections (eg, human immunodeficiency virus, TORCH)

Syndromes (eg, Russell-Silver, Turner, Down)

Chronic disease (eg, cardiac, renal, endocrine)

EvaluationEvaluation

Clinical History Complete Physical Examination

Judicious Lab tests and other inv

HistoryHistory

Birth : IUGR,LBW,Prematurity, prenatal exposure alcohol, drugs

Chronic diseases Recurrent infections Frequent injuries Review of systems

Feeding historyFeeding history

Kind, amount of formula Preparation of formula Excessive low calorie liquid/fruit

Stool pattern, vomiting with feeding

Special diet, vegetarian Breast feeding techniques CALORIE COUNT

Feeding historyFeeding history

Feeding environment Feeding behaviour/interactions

Family historyFamily history

Family members’ heights and

weights History of illness Developmental delay MID-PARENTAL HEIGHT FAMILY GROWTH TREE

Psychosocial History

Psychosocial History

Financial & Employment status

Parental depression Substance abuse Family discordance /stress

Maladaptive parental styles

Physical Examination

Physical Examination

Begin with measurements – if all parameters are <5th percentile, 70%chance of organic etiology

Need to follow pattern of growth (i.e.,isolated points are meaningless)

Dysmorphism Palate intact Hypotonia or spasticiy Signs of neglect (diaper rashes, impetigo,

poor hygiene, protuberant abdomen)

Laboratory evaluationLaboratory evaluation

Guided by clinical evaluation

No evidence extensive screening lab tests

Sever malnutrition: albumin, alkaline phosphatase, calcium, phosphorous

Diagnostic imaging studies based on clinical evaluation

Diagnosis FTTDiagnosis FTT

TreatmentTreatment

Nutrition Repletion Treatment of underlying disease

Assessment oromotor function

Food intake 110-120% recommended intake

TreatmentTreatment

Increased food intake; high calorie formula

Enrichment of food: supplementation with minerals and protein

Tube feeding/parentral feeding

TreatmentTreatment

Addressing psychosocial stresses

Development and behavioral assessment

Child protection services

HospitalizationHospitalization

Severe malnutrition Significant dehydration Serious intercurrent illness or

significant medical problems Psychosocial circumstances that put the

child at risk for harm Failure to respond to several months of

outpatient management Precise documentation of energy intake Extreme parental impairment or anxiety Extremely problematic parent-child

interaction Practicality of distance,

transportation, or family psychosocial problems preclude outpatient management

Refeeding syndromeRefeeding syndrome

Unknown pathology Post nutrition rehabilitation in severe malnourishment

Changes in electrolytes( low phosphate, Mg,K)

Disruption fluid balance, edema Impaired Heart function, hypoglycemia Prevention by increased K, Phos,Mg during repletion

Montiore blood sugar,electrolytes,blood gases, wt,U/A

SequelaeSequelae

Early onset FTT, persistent reduction in Wt, Ht

Long term adverse effects cognition, learning, behavior