discussion failure to thrive

8/7/2019 discussion Failure to thrive

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Failure to thrive


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Definition

Growth failure or failure to thrive is a term usedfor describing inadequate growth in earlychildhood.

It is applied to children whose current weight orrate of weight gain is significantly below (lessthan the fifth percentile) other children of similarage and sex.

It covers poor physical growth of any cause anddoes not imply abnormal intellectual, social, oremotional development


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The first thing that pediatricians should do in

all health assessments is to plot the head

circumference, height, and weight on a

growth chart

Previous growth parameters should be used to

detect trends in growth rather than relying on

measurements at one particular visit


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Normal growth (weight)

1) Term infant

First week

The average birth weight for a term infant is 3.3 kg

Weight drops as much as 10% in the first few days of life, secondary to loss ofexcess fluid

By 10-14 days of life, birth weight should be regained.

Breastfed infants who are fed smaller volumes of colostrum for the first few daysregain birth weight a little later than bottle-fed infants

Proper weight gain for infants

First 3 months: 1 kg/month

3-6 months: 0.5 kg/month

6-9 months: 0.33 kg/month

9-12 months: 0.25 kg/mo

4-6 months: double their birth weight

12 months: triple their weight

Until a toddler: roughly 0.25

Early school age: 2 kg/year


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Normal growth (Length)

Length

First year: 25 cm in length

Second year: 12.5 cm

4 years to puberty: 5-6cm

Puberty: 12 cm per year

Head circumference

At birth: 35 cm

1 year: 47 cm

6 years: 55 cm

Upper lower body segment ratio

The upper-to-lower body segment ratio changes with growth

Normally, the ratio at birth is 1.7, the ratio at age 3 years is 1.3, and theratio by age 7 years becomes 1.

The lower body segment is measured from the symphysis pubis to the

floor.


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Normal growth

2) Pre-mature infant

When plotting growth charts for premature babies, a "corrected age" should beused.

This corrected age can be calculated by subtracting the number of weeks ofprematurity from the postnatal age.

Special growth charts based on gestational age rather than chronological age havebeen developed for infants, beginning at 26 weeks' gestational age. However,because these charts represent a compilation of a relatively small number ofinfants, they may not be completely reliable.

Whichever technique is used for premature babies (eg, adjustment of age, usingspecific premature growth charts), consistency of methodology is essential.

Once a method for plotting growth is chosen, that technique should be followedeach time plotting occurs.

Prior to 40 weeks' gestation, some infants may require as much as 120 kcal/kg/d toensure adequate weight gain.

Catch-up growth is attained at approximately age 18 months for headcircumference, age 24 months for weight, and age 40 months for height.

Subsequently, normal growth charts can be used. In some premature babies withvery low birth-weight, catch-up growth does not occur until early school age.


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Nutrition for growth

The child's nutrient needs correspond with these changes in growthrates

An infant needs more calories in relation to size than a preschooleror school-age child needs

Nutrient needs increase again as a child gets close to adolescence

Generally, a healthy child will follow an individual growth curve,even though the nutrient intake may be different for each child

Parents and caregivers should provide a diet that is appropriate fortheir child's age. They should offer a wide variety of foods to ensuretheir child is getting enough nutrition

Adequate intake in a normal infant is

First half year: 100-110 kcal/kg/d

Second half of the first year: 100kcal/kg/d

10 kg-20 kg: 50 kcal/kg/d

> 20 kg: 20 kcal/kg/d


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Causes

It is important to determine whether failure to

thrive results from medical problems or

factors in the environment, such as abuse or

neglect


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Prenatal causes

Prematurity with complications

Maternal malnutrition

Toxic exposure in utero

Alcohol, smoking, medications, infections

IUGR

Chromosomal abnormalities


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Post natal causes

Inadequate intake

Lack of appetite (chronic illness)

Inability to suck or swallow (cleft palate etc)

Vomiting

Therapy used to treat primary illness (eg, chemotherapy, steroids)

Developmental delay

GI pain or dysmotility Poor absorption and/or use of nutrients

Malabsorption

Anatomical GI problems

Pancreatic and cholestatic conditions

Inborn errors of metabolism

Chronic GI infections

Increased metabolic demand

HIV infection

Malignancy

Cardiopulmonary diseases and inflammatory conditions

Renal failure

Hyperthyroidism


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Environmental and social causes

Emotional deprivation as a result of parentalwithdrawal, rejection, or hostility

Parental dysfunction

Economic problems that affect nutrition, livingconditions, and parental attitudes

Exposure to infections, parasites, or toxins

Poor eating habits, such as eating in front ofthe television and not having formal mealtimes


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Risk factor

Infants from families with social, economic, or

mental health problems

Other risk factors include depression in amother or primary care giver, stress, alcohol

or drug abuse, and lack of warmth toward the

infant


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Signs Infants or children who fail to thrive have a height, weight,

and head circumference that do not match standardgrowth charts.

The person's weight falls lower than 3rd percentile (asoutlined in standard growth charts) or 20% below the ideal

weight for their height Growing may have slowed or stopped after a previously

established growth curve

Child will be delayed or slow to develop according tonormal developmental milestones:

a) Physical skills such as rolling over, sitting, standing andwalking

b) Mental and social skills

c) Secondary sexual characteristics (delayed inadolescents)


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Diagnosis

Health care providers, during well-baby exams, usestandard growth charts, and weight, length and headcircumference measurements to determine if there isany problem with growth

If a child falls below his or her weight range for age, ordoes not gain weight at the expected rate, the healthcare provider will do a careful history and exam.

The doctor will perform a physical exam and check thechild's height, weight, and body shape. A detailedhistory is taken, including prenatal, birth, neonatal,psychosocial, and family information.


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History

The most important part of the evaluation of a child with failure to thrive (FTT) isobtaining a careful, detailed history. Once identified, the history can revealwhether the failure to thrive is organic, nonorganic (no identifiable physicalconditions contributing to the problem),or has components of both.

The next step is to establish whether the parent of a child with organic failure tothrive feels that it is related to decreased intake, increased losses (eg, diarrhea,

emesis) or abnormal metabolism (chronic illnesses, especially cardiopulmonaryillnesses that increase the basal metabolic rate). Often times, multiple factors cancontribute in a single patient.

The history should include the following:

1. Prenatal history: This should include information regarding smoking, alcoholuse, use of medications, illnesses (including rashes), and any data on prenatalgrowth.

2. A review of the events in the nursery: This should include feeding problemsand medical conditions, especially those that delay discharge.

3. Detailed feeding history (with a documentation of how many ounces or litersare consumed in a 24-hour period rather than 3 oz every 3 h): Breast-fedbabies should have 7 or more wet diapers per day and regular passage ofstools.


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4. Description of the type of solid foods eaten (including the quantitativecomposition and frequency of meals and snacks): If a detailed history is difficultto obtain, parents should bring in a 3-day food diary, as well as the jars and/orlabels from foods that the child is eating. Nutritionists are helpful in interviewingparents and calculating the exact number of calories consumed.

5.Previously charted growth: Old growth charts should be referred to when

analyzing the data. If any changes in rate of weight gain are noted, the primarycare taker should be asked about changes in feeding and additional changes,including introduction of new foods, change in formula, change from breast milkto formula, and changes in the primary individuals responsible for feeding thechild. Finally, any changes in family dynamic should be investigated.

6. Details about any illnesses that occurred since the neonatal period (particularlythose that require hospitalization or are chronic and/or permanent)

7. Medical problems that can compromise eating (eg, cleft palate, cerebral palsy,spasticity, seizures, and delayed development) and require closer scrutinyregarding caloric intake

8. Family and social history: This should include growth and eating pattern of othersiblings, living conditions, stressors, and data on parents' growth history.


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Physical examination

The physical examination may reveal the following abnormalities in children withunderlying medical conditions that causes failure to thrive:

Edema including ascites - Renal disease, liver disease, protein-losing enteropathy

Wasting - Cancer, HIV, CP, poorly controlled inflammatory disease

Hepatomegaly - Liver infiltration by tumor, storage disease, or cirrhosis

Heart murmur - Congenital heart disease Respiratory compromise -Cystic fibrosis, bronchopulmonary dysplasia

Rash or skin changes - HIV, congenital syphils, cow's milk protein allergy, lupus

Hair color and texture changes - Zinc deficiency, Menkes kinky hair disease

Mental status changes Cerebral Palsy

Signs of vitamin deficiency -Celiac disease, parasites, other enteropathy

Decreased weight secondary to marasmus (caused by insufficient caloric intake)should be distinguished from decreased weight secondary to acute dehydration.

Only acute dehydration is characterized by decreased skin turgor, sunken anteriorfontanelle, dry mucous membranes, absence of tears, and acutely ill appearance


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Diagnosis

The following laboratory tests may be done if suspectunderlying medical condition and determine childphysical status:

Complete blood count (CBC) Electrolyte balance

Hemoglobin electrophoresis to determine thepresence of conditions such as sickle cell disease

Hormone studies, including thyroid function tests

X-rays to determine bone age

Urinalysis


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Sample of Growth charts


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If weight, height,and headcircumference areall compromised,this suggests an inutero insult and/or

genetic orchromosomalabnormality


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Growth failure in

length and

weight with a

normal head

circumference

in an infant

with growthhormone

deficiency


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Acquired

hypothyroidism


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Constitutional

delay of

growth


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Failure to thrive

secondary to

caloric

deprivation

Head

circumference is

delayed


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Treatment

Treatment depends on the cause. In case of medicalproblems, specific treatment is given according to thecondition

In case of environmental factors and poor nutrition, the

child can be treated at home with nutritious high-caloriefeeding

In cases of failure to thrive that are thought to be caused bycaregivers' or parents' actions, a social worker and apsychologist or other mental health professional may help

address problems in the home environment and provideany needed support

More severe cases may require tube feeding; and a childwith extreme failure to thrive may need to be hospitalized

discussion failure to thrive

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