Download - Adepoju - Failure to Thrive
-
8/3/2019 Adepoju - Failure to Thrive
1/37
-
8/3/2019 Adepoju - Failure to Thrive
2/37
Overview Definition
Introduction
Risk factors
Classification Etiology
D/D&Diagnosis
Investigations & Management Outcome &Prognosis
Top 6 things to remember about FTT
-
8/3/2019 Adepoju - Failure to Thrive
3/37
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)
-
8/3/2019 Adepoju - Failure to Thrive
4/37
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
-
8/3/2019 Adepoju - Failure to Thrive
5/37
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
-
8/3/2019 Adepoju - Failure to Thrive
6/37
Risk Factors
These Can Be Subdivided IntoCharacteristics Of:
The Child
The Parent
The Society
(Nelson 2004)
-
8/3/2019 Adepoju - Failure to Thrive
7/37
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
-
8/3/2019 Adepoju - Failure to Thrive
8/37
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)
-
8/3/2019 Adepoju - Failure to Thrive
9/37
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)
-
8/3/2019 Adepoju - Failure to Thrive
10/37
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)
-
8/3/2019 Adepoju - Failure to Thrive
11/37
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*
-
8/3/2019 Adepoju - Failure to Thrive
12/37
Etiology
Inadequate absorption
Celiac disease
Cystic fibrosis
Milk allergy
Vitamin deficiency
Biliary Atresia
Necrotizing enterocolitis (Nelson 2004)
-
8/3/2019 Adepoju - Failure to Thrive
13/37
Etiology
Increased metabolism Hyperthyroidism Chronic infection Congenital heart disease
Chronic lung disease
Other considerations Genetic abnormalities, congenital infections,
metabolic disorders (storage diseases, aminoacid disorders)
-
8/3/2019 Adepoju - Failure to Thrive
14/37
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
http://gpnotebook.co.uk/simplepage.cfm?ID=-1744437248&linkID=62859&cook=yeshttp://gpnotebook.co.uk/simplepage.cfm?ID=-442892282&linkID=62860&cook=yeshttp://gpnotebook.co.uk/simplepage.cfm?ID=1765081110&linkID=62861&cook=yeshttp://gpnotebook.co.uk/simplepage.cfm?ID=-1684406195&linkID=62862&cook=yeshttp://gpnotebook.co.uk/simplepage.cfm?ID=-1865416697&linkID=62863&cook=yeshttp://gpnotebook.co.uk/simplepage.cfm?ID=624230402&linkID=62864&cook=yeshttp://gpnotebook.co.uk/simplepage.cfm?ID=624230402&linkID=62864&cook=yeshttp://gpnotebook.co.uk/simplepage.cfm?ID=-1865416697&linkID=62863&cook=yeshttp://gpnotebook.co.uk/simplepage.cfm?ID=-1684406195&linkID=62862&cook=yeshttp://gpnotebook.co.uk/simplepage.cfm?ID=1765081110&linkID=62861&cook=yeshttp://gpnotebook.co.uk/simplepage.cfm?ID=-442892282&linkID=62860&cook=yeshttp://gpnotebook.co.uk/simplepage.cfm?ID=-1744437248&linkID=62859&cook=yes -
8/3/2019 Adepoju - Failure to Thrive
15/37
Aetiology: Serious ChronicDisease
These include:
Cerebral palsy Hepatic failure
Renal failure
Degenerative disorders
-
8/3/2019 Adepoju - Failure to Thrive
16/37
Vomiting
Indicator of general infection
Pyloric stenosis Gastro-oesophageal reflux
Hiatus hernia
Oesophageal incoordination UTI
-
8/3/2019 Adepoju - Failure to Thrive
17/37
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
-
8/3/2019 Adepoju - Failure to Thrive
18/37
D/Diagnosis
infants born prematurely who aregrowing below their age matchedpeers, and
infants with postnatal catch downgrowth (Kane 2003)
-
8/3/2019 Adepoju - Failure to Thrive
19/37
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
-
8/3/2019 Adepoju - Failure to Thrive
20/37
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?
-
8/3/2019 Adepoju - Failure to Thrive
21/37
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
-
8/3/2019 Adepoju - Failure to Thrive
22/37
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
-
8/3/2019 Adepoju - Failure to Thrive
23/37
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?
-
8/3/2019 Adepoju - Failure to Thrive
24/37
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
-
8/3/2019 Adepoju - Failure to Thrive
25/37
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
-
8/3/2019 Adepoju - Failure to Thrive
26/37
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
-
8/3/2019 Adepoju - Failure to Thrive
27/37
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
-
8/3/2019 Adepoju - Failure to Thrive
28/37
Management
Do you hospitalize?
Necessary
Consider if:
the child has failed outpt management
FTT is severe
Medical emergency if wt
-
8/3/2019 Adepoju - Failure to Thrive
29/37
Management
For difficult cases:
Multidisciplinary team approachproduces better outcomes
Dietitians
Social workers
Occupational therapists
Psychologists
NG tube supplementation may benecessary
-
8/3/2019 Adepoju - Failure to Thrive
30/37
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)
-
8/3/2019 Adepoju - Failure to Thrive
31/37
Outcomes and Prognosis
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
-
8/3/2019 Adepoju - Failure to Thrive
32/37
Outcomes and Prognosis
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
-
8/3/2019 Adepoju - Failure to Thrive
33/37
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
-
8/3/2019 Adepoju - Failure to Thrive
34/37
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.
-
8/3/2019 Adepoju - Failure to Thrive
35/37
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
-
8/3/2019 Adepoju - Failure to Thrive
36/37
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
-
8/3/2019 Adepoju - Failure to Thrive
37/37
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/