failure to thrive
DESCRIPTION
S. U. S. FAILURE TO THRIVE. By William Bithoney Patrick Casey Robert Karp. Failure to Thrive. Abnormal weight status during infant-toddler years and/or Abnormal weight gain (weight growth velocity ). Abnormal weight status Referenced against:. - PowerPoint PPT PresentationTRANSCRIPT
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ByWilliam Bithoney
Patrick CaseyRobert Karp
FAILURE TO THRIVE
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Failure to Thrive
Abnormal weight status during infant-toddler years
and/or
Abnormal weight gain (weight growth velocity)
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Abnormal weight status Referenced against:
• Genetic growth expectations for family• Children of same gender and gestation
adjusted age – <5% on NCHS curves
• Child's own length – <10-25% on NCHS curves
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Abnormal weight gain (Growth Velocity)
• Falling across two standard deviation percentile lines on NCHS curves over 6 month period
• For at least one to two months
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FTT Definition includes:
"light""thin"
atypical weight gain
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Cautions Regarding Definition of Failure-to-Thrive
• Genetically small due to parents size • Children born small for gestational
age (SGA) may never catch up• If born larger than long-term genetic
potential demonstrate decreased growth rate in first 2 years
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FTT Definition: Growth Only
• Not necessarily associated with developmental/emotional problems in child
• Not necessarily environmental causation
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What's in a name?
Growth DelayGrowth FailureFailure to Grow
Growth DeficiencyFailure to Gain Weight
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FTT of long duration (Grown Older)
STUNTED:• Abnormal length and head
circumference• Psychosocial Dwarf?
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Failure-to -thrive Cause:
All children with Failure-To Thrive
are Undernourished
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Three Methods to Categorize Undernutrition in Children
Degree of Under-Nutrition
NoneMildModerateSevere
Gomez:% medianweight-for age
>9075-9060-74<60
Waterlow:% medianweight-for-height
>9080-9070-79<70
McLaren,Read:% median wt/htfor age ratios
>9085-9075-84<75
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Categorization of Undernutrition in 258 Children Referred for "Failure to Thrive"
Degree of Under-Nutrition
NoneMildModerateSevere
Gomez
No.
51321129
%
251434
Waterlow
No.
64149423
%
2558161
McLaren,Read
No.
183815646
%
7156018
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Clinical Subtypes
I. Medical Cause– Organic vs. Non-organic vs. Mixed
II. Clinical Presentation – Age of onset– Severity– Chronicity
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• Organic Etiology:– medical disease present and clinically judged to be sole
cause of FTT
• Non-organic Etiology:– problems in the child's environment judged to be the
primary cause of FTT, in the presense or absence of medical disease
• MIXED Etiology:– medical problem and problems in environment in
combination are judged to be cause of FTT
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Problems with Organic/Non-Organic Dichotomy
1. It is often difficult to place a child in either category
2. The dichotomy fails to account for the compounding effect of problems in both the child and the environment
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Problems with Organic/Non-Organic Dichotomy (Cont'd)
• 3. Children with either may have symptoms like diarrhea or vomiting
• 4. Children with either may gain weight while in the hospital
• 5. Global terminology is not specific enough to develop an individualized management plan
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Clinical Subtypes (Cont'd)
III. Socioemotional
0-3 months
4-10 months
11-36 months
Homeostasis
Attachment disorder
Separation individuation disorder
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Clinical Subtypes (Cont'd)
IV. Psychiatric DiagnosesFeeding DisorderDepressionReactive Attachment Disorder
V. Mechanical Feeding DisorderFood Avesion
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Transactional FTT
Multiple aspects (overt or subtle) of child, parents, and the proximal and distal environments interact across time to result in FTT.
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Final Diagnosis of 131 Cases of Failure to Thrive
Non-organic
Interactional
Organic
Unknown
Number59
46
22
4
Percent45
35
16.7
3.3
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Frequency of Organic Systems Causing Failure to Thrive
GastrointestinalNeurologicalRespiratory-PulmonaryCardiovascularEndocrineOther
Most Common
Least Common
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Prevalence of Failure to Thrive
• 3.5% of admissions to children's hospitals
• 10% of clinic visists in urban and rural outpatient settings
• up to 16% 0-4 year olds in low income populations are "stunted"
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Failure to Thrive
• Weight is abnormally 2 standard deviations below the mean for gestation corrected age -- and/or
• weight crossess percentile curves by two standard deviations
• weight to height ratio is depressed
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"My baby is just small for her age"
-Parent
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Failure to Thrive: Spectrum of Causes
Problem in the Child
ORGANIC
Problem in theEnvironment
NON-ORGANIC
Interactive
Effects
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Parent Functioning
Child Outcomes•Development•Learning•Behavior•Growth•Health
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Goals of Clinical EvaluationIdentify conditions which:1. Negatively affect growth potential (disease)2. Increase basic caloric needs (e.g. chronic
infection)3. Decrease availability/utilization of calories
(e.g., malabsorption)4. Negatively affect parents ability to meet
nutritional needs (can't/won't eat)
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Diagnostic Evaluation
1. Growth assessment – confirm the diagnosis with weight and
height, present and past
2. History– predisposing factors
3. Physical examination– significant findings other than
malnutrition
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Diagnostic Evaluation (Cont'd)
• 4. Development-Behavioral Assessment– Assess delays in cognitive, language, or
motor functioning– Identify any behavioral abnormalities
• 5. Laboratory Evaluation– Varies for each child– Stepwise approach is recommended
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Laboratory Evaluation
• Should be directed by findings from the history and physical examination
• Document nutritional status:– albumin, iron, zinc
• Child may have endemic problem: – Tbc, AIDS, giardia
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Diagnostic Evaluation (Cont'd)
• 6. Nutritional and Feeding Evaluation– Content and structure of mealtimes – Feeding techniques
• 7. Social History– Identify parental/family strengths and
weaknesses
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• 8. Parent/Child Interaction– Especially as it relates to feeding
• 9. Psychiatric Evaluation– Important if the caregivers emotional
state is adversely affecting parent-child interaction
Diagnostic Evaluation (Cont'd)
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Hospitalization vs. Outpatient Care
• Advantages of hospitalization:– Able to observe and control feeding– Able to observe the parent-child interaction– Medical evaluation can be done easily
• Disadvantages of hospitalization:– Cost– Child (and parent) are away from their
normal environment
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Indications for Hospitalization of Children with Failure-to-Thrive
1. Evidence of physical abuse2. Extreme failure to thrive (starvation)3. Extremely dysfunctional parent-child
relationship or family4. When distance and transportation issues
mean outpatient management is not practical
5. When outpatient management has failed
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Management of the Child with Failure-to-Thrive
1. Nutritional asessment and intervention2. Improved parent-child interaction3. Developmental stimulation4. Treatment/management of medical
conditions5. Support and intervention for social and
family problems6. Mental health referrals where indicated7. Regular follow-up care
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Best Predictors of Prognosis
• Age of onset, chronicity• Ongoing quality of the home
environment
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Interactional Model of Failure-to-Thrive
PARENT•Economic Status•Health•Knowledge•Emotional State•Past Experience
CHILD•Appearance•Health•Neuro developmental maturity•Ease of Caregiving
Parent-Child Interaction
Failure-to-Thrive
Endocrine-CellularDysfunction
Nutritional Deficiency
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Environmental Characteristics: Supports and Stressors
• Home– -Marital Relationship– -Physical Quality– -Organization– -Stability– -Economic Resources
• Family• Neighborhood and Work