adepoju - failure to thrive

8/3/2019 Adepoju - Failure to Thrive

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Overview Definition

Introduction

Risk factors

Classification Etiology

D/D&Diagnosis

Investigations & Management Outcome &Prognosis

Top 6 things to remember about FTT


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Definition

Failure to Thrive (FTT): Weight below the 5th percentile for ageand sex

Weight for age curve falls across two

major percentile lines Sub optimal weight gain and growth

in infants and toddlers

Remember 3% normal kids fall

below 3rd centileOther definitions exist, but are notsuperior in predicting problems

(Kirkland 2006)


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Introduction

Failure to thrive (FTT): A sign that describes a problem rather than a

diagnosis Usually describes failure to gain wt

In more severe cases length and head circumferencecan be affected

Underlying cause is insufficient usablenutrition to meet the demands for growth

Approximately 25% of normal children willhave a shift down in their wt curve of upto 25%, then follow a normal curve -- thisis not failure to thrive


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Introduction

Specific infant populations-

Premature/IUGR wt may be less than5th percentile, but if following the

growth curve and normal intervalgrowth then FTT should not bediagnosed

Modified growth charts exist for specificpopulations


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Risk Factors

These Can Be Subdivided IntoCharacteristics Of:

The Child

The Parent

The Society

(Nelson 2004)


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Child Characteristics

Some helpful features include: Mental alertness to surroundings - at the extreme

described as frozen watchfulness Absent exploration but sustained vigilance Increased appetite and disturbed feeding behaviors Forming indiscriminate attachments in hospital Seeking attention Demonstrating aggressiveness Immature play Decreased inter-personal interaction

Dull, pale skin Physically apathetic The mentally handicapped may be at greater risk of abuse


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Parental Characteristics

These are generalizations, but helpfulfeatures may be as follows:

Low intellect combined with lack ofknowledge, judgement and motivation

Severe depression/neurotic disorders Angry, hostile mothers who feel

persecuted by infants Chaotic lives and relationships

Chronic medical problems Substance abuse (Nelson 2004)


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Socio-cultural Factors

These are generalisations, butthere can be interactions of:

Parental isolation

Poor parental functioning

Lack of resources - for examplepoverty

Cultural understanding of what isappropriate (Nelson 2004)


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Classification

Historically has been divided into organicand nonorganic causes Most cases have mixed etiologies

This classification system is out of favor

More useful classification system is: Inadequate caloric intake

Inadequate fat or carbohydrate absorption

Increased energy requirements (Nelson 2004)


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Etiology

Inadequate Caloric Intake

Incorrect preparation of formula

Poor feeding habits (ex: too much juice)

Poverty Mechanical feeding difficulties (reflux, cleft

palate, oromotor dysfunction)

Neglect

Physicians are strongly encouraged to consider childabuse and neglect in cases of FTT that dont respondto appropriate interventions*


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Etiology

Inadequate absorption

Celiac disease

Cystic fibrosis

Milk allergy

Vitamin deficiency

Biliary Atresia

Necrotizing enterocolitis (Nelson 2004)


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Etiology

Increased metabolism Hyperthyroidism Chronic infection Congenital heart disease

Chronic lung disease

Other considerations Genetic abnormalities, congenital infections,

metabolic disorders (storage diseases, aminoacid disorders)


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Aetiology:Syndromes

There Are A Massive Number OfSyndromes Which Result In Failure ToThrive.

They Include: Down's Syndrome Foetal Alcohol Syndrome

Congenital Infections

Skeletal Dysplasias

Turner's Syndrome

Bartter's Syndrome
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Aetiology: Serious ChronicDisease

These include:

Cerebral palsy Hepatic failure

Renal failure

Degenerative disorders


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Vomiting

Indicator of general infection

Pyloric stenosis Gastro-oesophageal reflux

Hiatus hernia

Oesophageal incoordination UTI


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D/Diagnosis

The first consideration in aninfant presenting with presumedFTT is identifying normal variants of

growth. Within this group lie fourmain patterns

infants who have small parents

and are growing to their geneticpotential

infants with constitutional delay in

growth


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D/Diagnosis

infants born prematurely who aregrowing below their age matchedpeers, and

infants with postnatal catch downgrowth (Kane 2003)


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Diagnosis

Accurately plotting growth charts atevery visit is recommended*

Assess the trends

H&P more important than labs Most cases in primary care setting are

psychosocial or nonorganic in etiology


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History

Dietary Keep a food diary

If formula fed, is it being prepared correctly?

When, where, with whom does the child eat?

PMH Illnesses, hospitalizations, reflux, vomiting, stools?

Social Who lives in the home, family stressors, poverty, drugs?

Family Medical condition (or FTT) in siblings, mental illness,

stature?

Pregnancy/Birth Substance abuse? postpartum depression?


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Physical

Accurate measurement of childsheight, weight, head circumference

Single data point has limited usefulness

Evaluate for dysmorphic features

Mouth, palate

Neurologic exam

Signs of spasticity or hypotonia

Cardiovascular/Lung exam


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Physical

Signs of neglect or abuse Lack of age appropriate eye contact, smiling,

vocalization, or interest in environment

Chronic diaper rash

Impetigo

Flat occiput

Poor hygeine

Bruises

Scars


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Physical

Observe parent-child interactions

Especially during a feeding session

How is food or formula prepared?

Oral motor or swallowing difficulty?

Is adequate time allowed for feeding?

Do they cuddle the infant during feeds?

Is TV or anything else causing a distraction?


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Lab Evaluation Unless suggested by H&P, no routine lab

tests recommended initially* One study of hospitalized pts resulted in only 1.4% of

tests being of diagnostic assistance in FTT

If problem persists, could consider: CBC and film, U/A, Electrolytes, TSH, ESR, Lead,

HIV, Tb If not improving with adequate diet,

consider: Stool for fat, reducing substances, pathogens Celiac antibody testing

CF testing, Creatinine and electrolytes, plus liverand bone function

Thyroid function and other endocrineinvestigations

Sweat test,serum ferritin,B12&folate as

indicated.Chromosomoal studies


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Management

Goal is catch-up weight gain

Most cases can be managed with nutritionintervention and/or feeding behavior

modification (Bauchner 2004) General principles:

High Calorie Diet

Close Follow-up

Keep a prospective feeding diary-72 hour

Assure access to food programs, othercommunity resources


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Management

Energy intake should be 50% greaterthan the basal caloric requirement

Concentrate formula, add rice cereal topureed foods

Add taste pleasing fats to diet (cheese,peanut butter, ice cream)

High calorie milk drinks (Pediasure has 30cal/oz vs 19 cal per oz in whole milk)

Multivitamin with iron and zinc


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Management

Parental behavior

May need reassurance to help with their ownanxiety

Encourage, but dont force, child to eat Make meals pleasant, regular times, dont rush

May need to schedule meals every 2-3 hours

Make the child comfortable

Encourage some variety and cover the basicfood groups

Snacks between meals


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Management

Do you hospitalize?

Necessary

Consider if:

the child has failed outpt management

FTT is severe

Medical emergency if wt


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Management

For difficult cases:

Multidisciplinary team approachproduces better outcomes

Dietitians

Social workers

Occupational therapists

Psychologists

NG tube supplementation may benecessary


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Outcomes and Prognosis

Persistent disorders of growth

6 of 7 studies showed statisticallysignificant persistent poor growth (ht,wt, hc) in FTT group at up to 5 yearsfrom initial treatment.

Earlier intervention leads to better outcomes

(Krugman & Dubowitz 2003)


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FTT and Immunologic/InfectiousOutcomes

FTT children have significantly increased

susceptibility to infection (Kane 2003) Among hospitalized children increased

rates of bacteremia and mortality

Increased rates of upper and lowerrespiratory infections


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Concurrent Behavior disorders FTT groups scored lower on reports describing

affect and communications skills

Behavior disorders at follow-up Various trials have demonstrated significant

increase in behavioral problems

Cognitive Development There is a consistent association between FTT

and lower cognitive development test scores inpreschool and primary school children


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Prognosis cont

In the 1st year of life is ominous

1/3 children with psychosocialFTT are developmentally delayedand have social and emotionalproblems

Variable prognosis in organic FTT


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Top 6 take home points

1. Evaluation of Failure to Thrive involvescareful H&P, observation of feedingsession, and should include routine labor other diagnostic testing

2. Nutritional deprivation in the infant andtoddler age group can have permanenteffects on growth and brain development

3.

Treatment can usually occur by theprimary care physician in the outpatientsetting.


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Top 6 take home points

4. Psychosocial problems predominate asthe causes of FTT in the outpatientsetting (Block&Krebs 2005)

5. Treatment goal is to increase energyintake to 1.5 times the basalrequirement

6. Earlier intervention may make it easierto break difficult behavior patterns andreduce sequelae from malnutrition


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Summary: G.R.O.W.T.H.

Gather history and extensivephysical

Remember genetic contribution

Only order basic labs in initial eval Wonder and ponder on most likely

cause

Track growth trends Hospitalize or hormonally treat

(Logan 2005)10/08/11 Failure to Thrive 36


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Bibliography

1. Block RW, Krebs NF. Failure to thrive as a manifestation of child neglect.Pediatrics 2005 Nov; 116(5):1234-7. From National GuidlineClearinghouse www.guideline.gov

2. Kirkland, RT. Failure to thrive in children under the age of two. Up toDate:http://www.utdol.com/utd/content/topic.do?topicKey=gen_pedi/2884&type=P&selectedTitle=6~29 version 14.2, april 2006:pgs 1-8.

3. Krugman SD, Dubowitz H. Failure to thrive. American Family Physician,sept 1 2003. Vol 68 (5).4. Kane, ML. Pediatric Failure to Thrive. Clinics in Family Practice. Vol 5,

#2, June 2003, pages 293-311.5. Agency for Healthcare Research and Quality (AHRQ); Evidence report:

Criteria for Determining Disability in Infants and Children: Failure tothrive. #72, pages 1-54. http://www.ahrq.gov/clinic/

6. Bauchner, H. Failure to thrive, in Behrman: Nelson Textbook of

Pediatrics, 17th ed, chapter 35, 36 - 2004.7. Rudolf M, Logan S. What is the long term outcome for children who fail

to thrive? A systematic review. InArch Dis Child2005;90;925-931.
http://www.guideline.gov/http://www.guideline.gov/http://www.utdol.com/utd/content/topic.do?topicKey=gen_pedi/2884&type=P&selectedTitle=6~29http://www.utdol.com/utd/content/topic.do?topicKey=gen_pedi/2884&type=P&selectedTitle=6~29http://www.utdol.com/utd/content/topic.do?topicKey=gen_pedi/2884&type=P&selectedTitle=6~29http://www.ahrq.gov/clinic/http://www.ahrq.gov/clinic/http://www.ahrq.gov/clinic/http://www.utdol.com/utd/content/topic.do?topicKey=gen_pedi/2884&type=P&selectedTitle=6~29http://www.utdol.com/utd/content/topic.do?topicKey=gen_pedi/2884&type=P&selectedTitle=6~29http://www.guideline.gov/

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