failure to thrive for investigators · 3/16/2018  · • failure to thrive is a common problem....

3/16/2018

WI CAN Educational SeriesHillary W. Petska, MD, MPH, FAAP

Child Advocacy and Protection Services

Children’s Hospital of Wisconsin

• Normal patterns ofgrowth

• Definition andcauses of FTT

• Medical evaluationand management

• Effects of FTT

• Early intervention

• Infants typically lose5-10% of birthweight, but regainby 10-14 days

• Double birth weightby 5-6 months

• Triple birth weightby 1 year

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• Infants should be breast or formula fed until 1 yo

• Breastfed babies should be given Vit D

• Solids can be started around 6 mos

• At 1 yo, transition to whole cow’s milk (max: 24 ounces), low fat milk at 2 yo

• For kids > 1 yo, limit juice to 4-6 oz/d

• Not all diets are created equal.

• Cow milk or low iron formula – iron deficiency

• Goat milk – folatedeficiency

• Raw milk – infection risk

• Almond milk – multiple deficiencies

• Fruit juice – kwashiorkor

• Mostly diagnosed inchildren < 2 yo

• Seen in 5-10% ofchildren in primary care settings

• Accounts for 1-5% ofall referrals to children’s hospitals

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• Prolonged cessationof appropriate weightgain compared toage/gender norms

• Weight < 3rd

percentile

• Decline of weightacross 2 majorpercentiles in 6months

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Actual weightIdeal body weight

x 100

% of Ideal Body Weight

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• Decreased weight inproportion to length= FTT

• Inadequatenutrition: weight,then height, thenhead circumferenceaffected

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• Decreased length inproportion to weight =endocrine abnormality

• Isolated cessation ofhead circumferencegrowth = neurologicdisorder

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• Proportionatedecrease in weight-for-length withnormal growthvelocity ≠ FTT

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• Intrauterine growth restriction,prematurity, genetic shortstature, constitutional growthdelay

• Conditional growth charts forchildren with altered growthpatterns:

• Trisomy 21 (Downsyndrome)

• Prader-Willi syndrome• Williams syndrome• Cornelia deLange syndrome• Turner syndrome• Rubinstein-Taybi syndrome• Marfan syndrome• Achondroplasia

• •

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FTT is a sign, not a diagnosis

• Inadequate energy intake

• Inadequate nutrientabsorption

• Increased energyrequirements

May be due to a medical condition, psychosocial reasons, or both

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• Prematurity

• Congenital anomalies

• Developmental delay

• Intrauterine exposures

• Lead poisoning

• Dietary beliefs/practices

• Any condition that results in inadequate intake, malabsorption, or increased metabolic rate

• Poverty

• Social isolation

• Domestic violence

• Substance abuse

• Mental health

• Knowledge deficits

• Stress

• Comprehensivehistory and exam cantypically r/o medicalcauses

• Observation/historyof feeding:• Preparation of formula

• Oral-motor dysfunction

• Feeding environment

• Parent-child interaction

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• Hospitalizationmay be required:• Diagnostic work-

up

• Severe malnutrition or dehydration

• Refeedingsyndrome

• Protection

• Multidisciplinaryteam

• Feedingrecommendations

• Nutrition education

• Referral for resources

• Close follow-up

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• Neglect• Physical

• Environmental• Supervisory

• Medical• Emotional• Educational

• Abuse• Physical• Sexual

• Poor linear growth

• Decreased brain growth

• Lower IQ

• Developmental delay

• Behavioral problems

• Increased risk ofinfection

• Poor wound healing

• Weak bones

• Death

• General appearance

• Behavior

• Stealing, hoardingfood

• Disclosures

• Reports missingmeals

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• Inadequateformula/food

• No clean dishes

• No electricity

• No runningwater

• Safety hazards

• Follow-up with PMD

• Medical recordsrequest

• WIC records

• Interview of childand/or siblings at aChild AdvocacyCenter

• Medical/investigator collaboration

• Failure to thrive is a common problem.

• Failure to thrive is due to inadequate nutrition,although the underlying cause is typically multifactorial.

• Failure to thrive has significant short- and long-term health consequences.

• Failure to thrive may be a sign of child neglect.

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• Block RW, NF Krebs. Failure to thrive as a manifestation of child neglect. Pediatrics. 116(5):1234-1237; 2005.

• DeNavas-Walt C, Proctor BD, Smith JC. U.S. Census Bureau, Current Population Reports, P60-245. Income, Poverty, and Health Insurance Coverage in the United States: 2012. U.S. Government Printing Office: Washington, DC; 2013.

• DiMaggio DM, Cox A, Porto AF. Updates in infant nutrition. Pediatr Rev. 38(10):449-462; 2017.

• Failure to thrive. In: Pediatric Nutrition: Policy of the American Academy of Pediatrics. 7th ed. Elk Grove Village, Ill.: American Academy of Pediatrics. 663-700; 2014.

• Gahagan S. Failure to thrive: A consequence of undernutrition. Pediatr Rev. 27(1):e1-11; 2006.

• Harper NS. Neglect: failure to thrive and obesity. Pediatr Clin North Am. 61(5):937-957; 2014.

• Homan GJ. Failure to thrive: a practical guide. Am Fam Physician. 94(4):295-299; 2016.

• Jaffe AC. Failure to Thrive: Current Clinical Concepts. Pediatr Rev. 32(3):100-107; 2011.

• Jenny C (ed). Child Abuse and Neglect: Diagnosis, Treatment, and Evidence. Saunders: St. Louis; 2011.

• Kirkland RT, Motil KJ. Etiology and evaluation of failure to thrive (undernutrition) in children younger than2 years. UpToDate; 2013.

• The National Center on Addiction and Substance Abuse (CASA) at Columbia University. No safe haven: Children of substance-abusing parents. New York, NY: The National Center on Addiction and Substance Abuse (CASA) at Columbia University; 1999b.

• Osofsky JD. The impact of violence on children. Future Child. 9(3):33-49; 1999.

• Schwartz ID. Failure to thrive: an old nemesis in the new millennium. Pediatr Rev. 21(8):257-264; 2000.

• Tranchida, Vincent. The Pathology of Fatal Child Neglect. University of Wisconsin School of Medicine and Public Health. Monona Terrace Community and Convention Center, Madison, WI. 15 February 2013. Conference Presentation.

• I would also like to acknowledge Dr. Lynn K. Sheets and Dr. Angela L. Rabbitt who provided additional cases/slide content.