Mk Pg Slide Failure to Thrive

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FAILURE TO THRIVE( FTT)

Atan Baas SinuhajiSub Division of Pediatrics Gastroentero-HepatologyDepartment of ChildHealth,School of MedicineUniversity of Sumatera Utara/Adam Malik Hospital

Medan



GROWTH

Increase in themass of body tissues

ABSABS--BIKA FKUSUBIKA FKUSU 22

Anthropometric measurement

HeadCircumference

BodyLenght

BodyWeight



DevelopmentDevelopment


SkillSkill



Anthropometric asessment

At the spesific time Repeated visit

44

Poor Poor

Malnutrition F T T



55



Table 1. WATER LOW’S CLASSIFICATIONTable 1. WATER LOW’S CLASSIFICATION

NORMAL WASTING STUNTE

EIGHT/ AGE %100 70 70

EIGHT/ HEIGHT %

EIGHT/ AGE %

100

100

70

100

100

87



F.T.T

SUBOPTIMAL OF GROWTH

REPEATED VISIT



Malnutrition isMalnutrition isthe sine qua non ofthe sine qua non of


the failure to thriv the failure to thriv



MALNUTRITION

GENETIC

FTT

99

PSYCHOSOCIAL

Malnutrition : inadequate nutrients



CALORI / NUTRIENTSCALORI / NUTRIENTS

Intake

Stools Absorption

1010

Utilization

BasalMetabolism

Peripheral Utilization

Growth



IMPAIRED OFPERIPHERAL

UTILIZATION

BASAL UTILIZATION

NUTRIENTS

MALABSORPTION

INTAKE

1111

NUTRITIONINADEQUATE

MALNUTRITION



Etiology of growth disordersEtiology of growth disorders

1.1. Inadequate intake ofInadequate intake of

calories/nutrientscalories/nutrients2.2. Excessive calories/nutrientsExcessive calories/nutrients

losseslosses

4.4. Impaired of peripheralImpaired of peripheral

utilizationutilization – – Chronic infectionChronic infection

– – MalignancyMalignancy

1212

– –

– –MalabsorptionMalabsorption

3.3. Basal metabolismBasal metabolism

– – Fever Fever

– –HyperthyroideaHyperthyroidea

– – HyperkinesiaHyperkinesia

– – InfectionInfection

– –Congenital heartCongenital heartdiseasesdiseases

– – AnemiaAnemia

– –

Inborn errorsInborn errors – – HormonalHormonal



FTT CAUSED

BY BOWELDYSFUNCTION

INADEQUATE

CALORY INTAKE-QUALITY

-IGNORANCE

-ANOREXIA

EXCESSIVECALORY LOSS -VOMITING

-MALABSORPTIO

-PROTEIN LOSIN

1313

ENTEROPATHY

INCREASED

NEED - FEVER



DISORDER OF DIGESTION

1414

MALDIGESTION

MALABSORPTION



MALABSORPTION

FAILURE OF THE DIGESTIVESUBSTRACTS ACROSS LUMEN INTO

1515

MUCOSE

VESSELSBLOOD

LYMPH



MALABSORPTION

1.MALDIGESTION

1616

.3.PERISTALSIS

4. ABSORPTION AREA- SHORT GUT

- MUCOSAL INJURY



MALDIGESTION

DISORDERS

INTRALUMINAL INTRACELLULAR

1717

-GASTER-PANCREAS

-LIVER-GUT →→→→ ENTEROKINASE

(trypsinogen trypsin)

- MALTASE

- LACTASE- SUCRASE- GLUCOAMYLASE

•PEPTIDASE•LIPASE





Causes ofCauses of mumuccosaosal injuryl injury

1. Mucosal compromised

Malnutrition

Folic acid Deficiency

Iron Deficiency

Antioxidant Deficiency


Viral (rotavirus) Bacteria overgrowth

Antibiotica ( e.g. Neomycine )

3. Immunological disorder SIgA Deficiency

4. Parasitic Infestation

Giardiasis



Consequences ofConsequences of mumuccosaosallinjuryinjury

1.1. DiarDiarrhorhoeeaa

2.2. MalabsorpMalabsorpttiionon


3.3. PProteinrotein losing enteropathylosing enteropathy4.4. SensitiSensitizzaattiionon mamaccroro molemolecculeruler absorptionabsorption

5.5.NNeeccrotirotizing Enterocolitiszing Enterocolitis



CLASSIFICATION OF MALABSORPTION

1.SUBSTRACTS

2.SELETIVE/GENERALIZED

2121

3.OBTAINED –CONGENITAL--- ACQUIRED

4.PATHOPHYSIOLOGY

5.PATHOGENESE & ETIOLOGY



CARBOHYDRATE

FAT

PROTEIN

2222

SUBSTRACT

VITAMIN

MIXED OR GENERALIZEDI I

PAN MALABSORPTION



Pathogenese& etiology

Congenital & genetic

Bacterial overgrowth

Bile acid def.

2323

sensitization

nutritional

Drug induced



CARBOHYDRATE1. INTRALUMINAL ENZYME :

AMYLASE

2. BRUSH BORDER ENZYMEOLIGO/DISACHARIDASE

2424

3. ABSORPTION

4. COLONIC BACTERIA

•GLUCOSE

•FRUCTOSE

•GALACTOSE

SCFA

COLON NUTRITION



BOWEL NUTRITION

SMALLINTESTINE

COLON

2525

70% INTRALUMINAL30% INTRAVASAL

45% INTRALUMINAL55% INTRAVASAL



TRYGLYCERIDE

FATTY ACID GLYCEROL

2626

SHORTCHAIN FATTYACID (SCFA)

MEDIUM CHAIN FATTY ACID

(MCFA)

LONG CHAIN FATTY ACID(LCFA)

C<6

C=6-8(12)

C>12



DIGESTION & ABSORPTION OFFAT

1.EMULSIFICATION

2.LIPOLYSIS LIPASE

2727

.

4.ENTER INTO MUCOSE

5.RE-ESTERIFICATION

6.CHYLOMICRON

7.BLOOD/LYMPH VESSELS



MCT(MEDIUM CHAINTRIGLYCERIDE)

C=6-8(12)

2828

1.LIPASE 70%

2.NO BILE SALT

3.NO REESTERIFICATION

4.NO CHYLOMICRON FORMATION

5.PORTAL VEIN



DIAGNOSTIC OF FAT

MALABSORPTION1. MICROSCOPIC

2. FLOATING TEST (ROSSIPAL)

3. LIPIODOL ABSORPTION TEST

2929

4. SERUM CAROTEN

5. FAT BALANCE (VAN DE KAMER)6. STEATOCRITE



LIPIODOL ABSORPTION TEST

LIPIODOL FAT+IODINE

Drink of 5-10 mL

3030

BLOOD

URINE + AMYLUM 1%

DILUTION 1:1

1:2

1:8 (+) N



DIGESTION &ABSORPTION OF

PROTEIN1.INTRALUMINAL DIGESTION (HCL, PEPSIN)

3131

2.ACTIVATED PANCREATIC ENZYMES BYENTEROKINASE

3.PROTEOLYSIS→→→→

PEPTIDE & AMINO ACIDS4.MUCOSE →→→→ INTRACELLULER DIGESTION

5.PORTAL VEIN



MALABSORPTION

ACUTE CHRONIC DEF. ABD.

DISTENSION

3232

DEHYDRATION

- PERSISTENT DIARRHOEA- FAILURE TO THRIVE



TREATMENT OF MALABSORPTION1. ETIOLOGY

-INFECTION

-ENZYMS

2. DIETPREDIGESTED FORMULA

3333

3. SUPPORTIVE- WATER & ELECTROLYTES- VITAMIN & MINERAL

- PREVENTION OFMALNOURISHED

MALABSORPTION SYNDROME



MALABSORPTION SYNDROME

1. LACTOSE INTOLERANCE

2. COW’S MILK PROTEIN INTOLERANCE3. PCM

3434

4. CHOLESTASIS

5. PARASITIC INFESTATION

6. ANTIBIOTICS

7. POST ENTERITIS MALABSORPTION

L t I t lL t I t l



TerminologyTerminology

Lactose IntoleranceLactose Intolerance

Lactase Defisiency :Lactase Defisiency :Lactase Defisiency :Lactase Defisiency :Lactase Defisiency :Lactase Defisiency :Lactase Defisiency :Lactase Defisiency :

Low / absence activity of lactaseLow / absence activity of lactaseLow / absence activity of lactaseLow / absence activity of lactaseLow / absence activity of lactaseLow / absence activity of lactaseLow / absence activity of lactaseLow / absence activity of lactase →→→→→→→→ enzyme assay enzyme assay enzyme assay enzyme assay enzyme assay enzyme assay enzyme assay enzyme assay

Laktose Malabsorption :Laktose Malabsorption :Laktose Malabsorption :Laktose Malabsorption :Laktose Malabsorption :Laktose Malabsorption :Laktose Malabsorption :Laktose Malabsorption :Failure of the small intestine to absorb lactoseFailure of the small intestine to absorb lactoseFailure of the small intestine to absorb lactoseFailure of the small intestine to absorb lactoseFailure of the small intestine to absorb lactoseFailure of the small intestine to absorb lactoseFailure of the small intestine to absorb lactoseFailure of the small intestine to absorb lactose

3535

conformity with the testconformity with the testconformity with the testconformity with the testconformity with the testconformity with the testconformity with the testconformity with the test

Lactose Intolerance :Lactose Intolerance :Lactose Intolerance :Lactose Intolerance :Lactose Intolerance :Lactose Intolerance :Lactose Intolerance :Lactose Intolerance : clinicalclinicalclinicalclinicalclinicalclinicalclinicalclinical

symptoms/signssymptoms/signssymptoms/signssymptoms/signssymptoms/signssymptoms/signssymptoms/signssymptoms/signs



LACTOSE

The Primary Carbohydrate Of

Mammals Milk

3636

Breast Milk(7 %) Cow Milk(4 %)

Sea Lion Milk(0 %)



LACTOSELACTOSEGlucose &Glucose &

GalactoseGalactoseLactaseLactase••

3737

•• Smallest amountSmallest amount

•• No adaptive enzymsNo adaptive enzyms



PrimaryPrimary

DevelopmentalDevelopmental

Congenital alactasiaCongenital alactasia

Late onset hypolactasiaLate onset hypolactasia

3838

DefisiencyDefisiency

SecondarySecondary

Mucosal damage egMucosal damage eg →→

rotavirus diarrhoearotavirus diarrhoea



UNABSORBED LACTOSEUNABSORBED LACTOSE

OSMOTICOSMOTICOSMOTICOSMOTICOSMOTICOSMOTICOSMOTICOSMOTIC ACTIONACTIONACTIONACTIONACTIONACTIONACTIONACTION

COLONCOLONCOLONCOLONCOLONCOLONCOLONCOLON

WATERWATERWATERWATERWATERWATERWATERWATER LACTOSELACTOSELACTOSELACTOSELACTOSELACTOSELACTOSELACTOSEABSORBEDABSORBEDABSORBEDABSORBEDABSORBEDABSORBEDABSORBEDABSORBED

FERMENFERMENFERMENFERMENFERMENFERMENFERMENFERMEN

TATIONTATIONTATIONTATIONTATIONTATIONTATIONTATION

GASESGASES

SHORT CHAIN FATTY ACIDSHORT CHAIN FATTY ACID

HH22

COCO22

CHCH44

3939

COLONICCOLONICCOLONICCOLONICCOLONICCOLONICCOLONICCOLONIC

SALVAGESALVAGESALVAGESALVAGESALVAGESALVAGESALVAGESALVAGE

•• OSMOTIC DIARRHOEAOSMOTIC DIARRHOEAOSMOTIC DIARRHOEAOSMOTIC DIARRHOEAOSMOTIC DIARRHOEAOSMOTIC DIARRHOEAOSMOTIC DIARRHOEAOSMOTIC DIARRHOEA

•• REDUCTION SUBSTANCE (LACTOSE)REDUCTION SUBSTANCE (LACTOSE)REDUCTION SUBSTANCE (LACTOSE)REDUCTION SUBSTANCE (LACTOSE)REDUCTION SUBSTANCE (LACTOSE)REDUCTION SUBSTANCE (LACTOSE)REDUCTION SUBSTANCE (LACTOSE)REDUCTION SUBSTANCE (LACTOSE) →→→→→→→→ CLINITESTCLINITESTCLINITESTCLINITESTCLINITESTCLINITESTCLINITESTCLINITEST

•• LACTAT ACIDLACTAT ACIDLACTAT ACIDLACTAT ACIDLACTAT ACIDLACTAT ACIDLACTAT ACIDLACTAT ACID →→→→→→→→ stools pHstools pHstools pHstools pHstools pHstools pHstools pHstools pH →→→→→→→→ LACMUSLACMUSLACMUSLACMUSLACMUSLACMUSLACMUSLACMUS

LL - - LACTATE LACTATE



DIAGNOSTIC OF LACTOSE INTOLERANCEDIAGNOSTIC OF LACTOSE INTOLERANCE

Lactose tolerance testLactose tolerance test

++

4040

ac ose ma a sorp on esac ose ma a sorp on esa.a. Stools pH & clini testStools pH & clini test

b.b. Lactose loading testLactose loading test

c. Breath hydrogen testc. Breath hydrogen test



Stools pH & clini testStools pH & clini test

Screening TestScreening Test

4141

• Only drunk lactose

• Fast intestinal transit time• Fresh stools

• Incomplete degradation of lactose



BreathBreathhydrogenhydrogen

testtest

4242

••Night fastingNight fasting

••Doses of lactose : 2Doses of lactose : 2 gr gr//kgBWkgBW (max. 50(max. 50

gr gr) in concentration of solution 20 %) in concentration of solution 20 %

••Samples are then collected every 30Samples are then collected every 30

minutes for 3 hours to determine Hminutes for 3 hours to determine H22

concentration in expired air concentration in expired air

••MalabsorptionMalabsorption : > 20: > 20 ppmppm greatergreaterthan fastin levelthan fastin level



TREATMENTTREATMENT

LACTOSE INTOLERANCELACTOSE INTOLERANCE

Primary Secondary

4343

1.1.Low/free lactoseLow/free lactose

2.2.PrematurePremature

-- Breast milk (+): continuedBreast milk (+): continued

-- Breast milk (Breast milk (--) : lactose lowered) : lactose lowered

+ glucose polymer + glucose polymer

Breast milk continued

Breast milk (Breast milk (--)) ????

COW’S MILK PROTEIN INTOLERANCE



COW S MILK PROTEIN INTOLERANCE

-SMALL BABY

-DIARRHOEA

-ENTEROPATHY

Lact. Intol. CMPI

4444

>>> >

(-) (+)

1.FREQ.

2.Extra GI Tractmanifestation

3.Phenomenon DOSE DEPENDENT DOSE INDEPEN.



Goldman CriteriaGoldman Criteria1.1. Remission of symptoms after eliminationRemission of symptoms after elimination

of cow milk from the dietof cow milk from the diet2.2. Relapse within 48 hours of beginning aRelapse within 48 hours of beginning a

4545

3.3. Positive reaction to 3 such challengesPositive reaction to 3 such challenges(similar onset, duration, and clinical(similar onset, duration, and clinical

features)features)



MUCOSAL

DAMAGE

BIOPSY

PERMEABILITY

4646

PROTEIN

LOSINGENTEROPATHY

-Dxylose absorption test

-L/M excretion ratio

-Polyethylen glycol abs. test



PROTEIN LOSINGENTEROPATHY

MUCOSALDAMAGE

INFLAMMATION

NONINFLAMMATION

4747

LYMPH OBSTR.

LYMPHANGIECTASIA

CHD*

*Congenital Heart Disease



DIAGNOSTIC OF PROTEIN LOSING

ENTEROPATHY

1. ISOTOP

2. FECAL α1- ANTITRYPSIN

4848

Mk Pg Slide Failure to Thrive

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