failure to thrive dr usha mallinath dr richard mones
TRANSCRIPT
Failure to ThriveFailure to Thrive
Dr Usha Mallinath
Dr Richard Mones
DefinitionDefinition
Wt below 3 rd centile Wt drops 2 major centiles
Wt for length below 3 rd centile
Wt < 80% ideal wt for age
Historic classification
Historic classification
Organic: those for which there is a clear genetic,
medical, or anatomic etiology, a very large
differential Nonorganic:
insufficient emotional or physical
nurturing without pathophysiological abnormality
Calories, CaloriesCalories, Calories
Root of growth failure stems from
inadequate calories Inadequate intake Increased demands Poor absorption Infants require
approximately110-120 kcal/kg/day
At age 1 year, 100 kcal/kg/day
Normal Weight GainNormal Weight Gain
Age Mean Daily weight gain
0-3 m 26-31g
3-6 m 17-18g
6-9 m 12-13 g
9-12 m 9 g
1-3 yr 7-9g
4-6yr 6g
EpidemiologyEpidemiology
1-5% tertiary hospital referrals
5% in 2006 in USA , CDC High incidence poverty, low socio-economic status
50% not identified by health care professions
Non organic FTT common in females
PathogenesisPathogenesis
Insufficient food intake Increase Energy Requirement
Malabsorption
PathogenesisPathogenesis
Insufficient food intake
Inadequate amount of food provided or available
Structural causes of poor feeding e.g. cleft palate, Treacher-Collins
Anorexia of chronic disease
PathogenesisPathogenesis
Malabsorption /Steatorrhea
Celiac disease Chronic Liver disease Cystic Fibrosis Chronic diarrhea
PathogenesisPathogenesis
Increase Energy Requirement
HIV Congenital Heart disease Hyperthyroidism
Etiology system based
Etiology system based
GI RS CVS Renal ID Genetic Heme/Onc Endocrine
GI CausesGI Causes
Feeding disorders Diarrhea
Cleft palate Infectious
Dentition Malabsorption
oro-motor
Vomiting Hepatic Biliary atresia
GERD Chronic Hepatitis
Stricture Cirrhosis
PulmonaryPulmonary
CF BPD Tonsilar/ Adenoidal hypertrophy
EndocrineEndocrine
Hypothyroid Rickets DM GH deficiency Adrenal insufficiency
Cardiac CausesCardiac Causes
Congenital cardiac disease/CHF POOR INTAKE ? Increased metabolic demands Possible fluid restrictions Early interventions which may interfere with development of normal suck/swallow coordination
IDID
HIV TB Parasites
Heme/OncHeme/Onc
Classic B-symptoms include
weight loss anorexia
GeneticGenetic
Chromosomal abnormalities Trisomy 13, 18, 21 Deletion of chromosome 22 Gonadal dysgenesis (45,X), etc
Evaluate for dysmorphisms
RenalRenal
Renal Tubular Acidosis Disorder of HCO3 and H+ reabsorption in renal tubules
Urine pH >5.5 in light of systemic
acidosis
Diagnostic Classification of causes: inadequate Nutrition Intake
Diagnostic Classification of causes: inadequate Nutrition Intake Not enough food offered
–Food insecurity –Poor knowledge of child's needs
Poor transition to table food Avoidance of high-calorie foods
–Formula dilution –Excessive juice –Breastfeeding difficulties –Neglect
Child not taking enough food –Oromotor dysfunction –Developmental delay –Behavioral feeding problem
Altered oromotor sensitivity Pain and conditioned aversion
Emesis –Gastroesophageal reflux –Malrotation with intermittent volvulus –Increased intracranial pressure
MalabsorptionMalabsorption
Cystic fibrosis Celiac disease Food protein insensitivity or intolerance
Increase Metabolic demands
Increase Metabolic demands
Insulin resistance (eg, intrauterine growth restriction)
Congenital infections (eg, human immunodeficiency virus, TORCH)
Syndromes (eg, Russell-Silver, Turner, Down)
Chronic disease (eg, cardiac, renal, endocrine)
EvaluationEvaluation
Clinical History Complete Physical Examination
Judicious Lab tests and other inv
HistoryHistory
Birth : IUGR,LBW,Prematurity, prenatal exposure alcohol, drugs
Chronic diseases Recurrent infections Frequent injuries Review of systems
Feeding historyFeeding history
Kind, amount of formula Preparation of formula Excessive low calorie liquid/fruit
Stool pattern, vomiting with feeding
Special diet, vegetarian Breast feeding techniques CALORIE COUNT
Feeding historyFeeding history
Feeding environment Feeding behaviour/interactions
Family historyFamily history
Family members’ heights and
weights History of illness Developmental delay MID-PARENTAL HEIGHT FAMILY GROWTH TREE
Psychosocial History
Psychosocial History
Financial & Employment status
Parental depression Substance abuse Family discordance /stress
Maladaptive parental styles
Physical Examination
Physical Examination
Begin with measurements – if all parameters are <5th percentile, 70%chance of organic etiology
Need to follow pattern of growth (i.e.,isolated points are meaningless)
Dysmorphism Palate intact Hypotonia or spasticiy Signs of neglect (diaper rashes, impetigo,
poor hygiene, protuberant abdomen)
Laboratory evaluationLaboratory evaluation
Guided by clinical evaluation
No evidence extensive screening lab tests
Sever malnutrition: albumin, alkaline phosphatase, calcium, phosphorous
Diagnostic imaging studies based on clinical evaluation
Diagnosis FTTDiagnosis FTT
TreatmentTreatment
Nutrition Repletion Treatment of underlying disease
Assessment oromotor function
Food intake 110-120% recommended intake
TreatmentTreatment
Increased food intake; high calorie formula
Enrichment of food: supplementation with minerals and protein
Tube feeding/parentral feeding
TreatmentTreatment
Addressing psychosocial stresses
Development and behavioral assessment
Child protection services
HospitalizationHospitalization
Severe malnutrition Significant dehydration Serious intercurrent illness or
significant medical problems Psychosocial circumstances that put the
child at risk for harm Failure to respond to several months of
outpatient management Precise documentation of energy intake Extreme parental impairment or anxiety Extremely problematic parent-child
interaction Practicality of distance,
transportation, or family psychosocial problems preclude outpatient management
Refeeding syndromeRefeeding syndrome
Unknown pathology Post nutrition rehabilitation in severe malnourishment
Changes in electrolytes( low phosphate, Mg,K)
Disruption fluid balance, edema Impaired Heart function, hypoglycemia Prevention by increased K, Phos,Mg during repletion
Montiore blood sugar,electrolytes,blood gases, wt,U/A
SequelaeSequelae
Early onset FTT, persistent reduction in Wt, Ht
Long term adverse effects cognition, learning, behavior