michener - failure to thrive

8/6/2019 Michener - Failure to Thrive

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Pediatric Failure toPediatric Failure to

ThriveThrive

Michael Michener, MDMichael Michener, MD

Major, USAFMajor, USAF14 March 200714 March 2007


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OverviewOverview

DefinitionsDefinitions

Case presentationCase presentation

IntroductionIntroduction DiagnosisDiagnosis

TreatmentTreatment

OutcomesOutcomes Top 6 things to remember about FTTTop 6 things to remember about FTT


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DefinitionDefinition

Failure to Thrive (FTT):Failure to Thrive (FTT): Weight below the 5Weight below the 5thth percentile for agepercentile for age

and sexand sex

Weight for age curve falls across twoWeight for age curve falls across twomajor percentile linesmajor percentile lines

Other definitions exist, but are notOther definitions exist, but are notsuperior in predicting problems orsuperior in predicting problems orlong term outcomeslong term outcomes


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Case PresentationCase Presentation

4 mo F, well child visit4 mo F, well child visit(Sept 06)(Sept 06) Mom complained aboutMom complained about

poor wt gainpoor wt gain Same problem with firstSame problem with first

childchild Husband deployedHusband deployed Parents small statureParents small stature Other development wasOther development was

normalnormal

Mom alleged thatMom alleged thatfeeding was going wellfeeding was going well(breastfeeding)(breastfeeding)

Wt = 10 lb 8 ozWt = 10 lb 8 oz


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Case PresentationCase PresentationWALSTON, KEIRA

02/579-13-8844

9 -A ug -0 6 2 .7 3 4.28 55.88 39.00

2-Nov-06 5.57 4.93 60.96

0.00

19-May-06 3.69 50.80

21-Aug-06 3.13 4.68 60.96 41.00

0.00

0.00

2 2- Se p- 06 4 .2 0 4.85 60.96 41.00

0.00

31-Oct-06 5.50 4.88 60.96

Went to ER at age 5Went to ER at age 5monthsmonths

Wt was down 1 lbWt was down 1 lb

Infant transferred to aInfant transferred to achildrens hospital forchildrens hospital forinpatient stayinpatient stay

Infant refusing to breastInfant refusing to breastor bottle feedor bottle feed

NG tube placedNG tube placed

4oz q4 hours4oz q4 hours

OT working with baby toOT working with baby tohelp with feedinghelp with feeding


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IntroductionIntroduction

Failure to thrive (FTT):Failure to thrive (FTT): A sign that describes a problem rather than aA sign that describes a problem rather than a

diagnosisdiagnosis Usually describes failure to gain wtUsually describes failure to gain wt

In more severe cases length and head circumferenceIn more severe cases length and head circumferencecan be affectedcan be affected

Underlying cause is insufficient usableUnderlying cause is insufficient usablenutrition to meet the demands for growthnutrition to meet the demands for growth

Approximately 25% of normal children willApproximately 25% of normal children willhave a shift down in their wt curve of uphave a shift down in their wt curve of upto 25%, then follow a normal curveto 25%, then follow a normal curve ---- thisthisisis notnot failure to thrivefailure to thrive


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Specific infant populationsSpecific infant populations--

Premature/IUGRPremature/IUGR wt may be less thanwt may be less than55thth percentile, but if following thepercentile, but if following thegrowth curve and normal intervalgrowth curve and normal intervalgrowth then FTT should not begrowth then FTT should not bediagnoseddiagnosed

Modified growth charts exist for specificModified growth charts exist for specificpopulationspopulations


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Historically has been divided into organicHistorically has been divided into organicand nonorganic causesand nonorganic causes Most cases have mixed etiologiesMost cases have mixed etiologies

This classification system is out of favorThis classification system is out of favor More useful classification system is:More useful classification system is:

Inadequate caloric intakeInadequate caloric intake

Inadequate fat or carbohydrate absorptionInadequate fat or carbohydrate absorption

Increased energy requirementsIncreased energy requirements


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EtiologyEtiology

Inadequate Caloric IntakeInadequate Caloric Intake

Incorrect preparation of formulaIncorrect preparation of formula

Poor feeding habits (ex: too much juice)Poor feeding habits (ex: too much juice)

PovertyPoverty

Mechanical feeding difficulties (reflux, cleftMechanical feeding difficulties (reflux, cleftpalate, oromotor dysfunction)palate, oromotor dysfunction)

NeglectNeglect

Physicians are strongly encouraged to consider childPhysicians are strongly encouraged to consider childabuse and neglect in cases of FTT that dont respondabuse and neglect in cases of FTT that dont respondto appropriate interventions*to appropriate interventions*

*(SOR*(SOR C, expert and consensus opinion, Ref 1)C, expert and consensus opinion, Ref 1)


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EtiologyEtiology

Inadequate absorptionInadequate absorption

Celiac diseaseCeliac disease

Cystic fibrosisCystic fibrosis Milk allergyMilk allergy

Vitamin deficiencyVitamin deficiency

Biliary AtresiaBiliary Atresia

Necrotizing enterocolitisNecrotizing enterocolitis


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EtiologyEtiology

Increased metabolismIncreased metabolism HyperthyroidismHyperthyroidism Chronic infectionChronic infection Congenital heart diseaseCongenital heart disease Chronic lung diseaseChronic lung disease

Other considerationsOther considerations Genetic abnormalities, congenital infections,Genetic abnormalities, congenital infections,

metabolic disorders (storage diseases, aminometabolic disorders (storage diseases, aminoacid disorders)acid disorders)


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DiagnosisDiagnosis

Accurately plotting growth charts atAccurately plotting growth charts atevery visit is recommended*every visit is recommended*

Assess the trendsAssess the trends H&P more important than labsH&P more important than labs

Most cases in primary care setting areMost cases in primary care setting arepsychosocial or nonorganic in etiologypsychosocial or nonorganic in etiology

*(SOR*(SOR C, expert and consensus opinion, Ref 1)C, expert and consensus opinion, Ref 1)


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HistoryHistory

DietaryDietary Keep a food diaryKeep a food diary

If formula fed, is it being prepared correctly?If formula fed, is it being prepared correctly?

When, where, with whom does the child eat?When, where, with whom does the child eat?

PMHPMH Illnesses, hospitalizations, reflux, vomiting, stools?Illnesses, hospitalizations, reflux, vomiting, stools?

SocialSocial Who lives in the home, family stressors, poverty, drugs?Who lives in the home, family stressors, poverty, drugs?

FamilyFamily Medical condition (or FTT) in siblings, mental illness,Medical condition (or FTT) in siblings, mental illness,

stature?stature?

Pregnancy/BirthPregnancy/Birth Substance abuse? postpartum depression?Substance abuse? postpartum depression?


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PhysicalPhysical

Accurate measurement of childsAccurate measurement of childsheight, weight, head circumferenceheight, weight, head circumference

Single data point has limited usefulnessSingle data point has limited usefulness

Evaluate for dysmorphic featuresEvaluate for dysmorphic features

Mouth, palateMouth, palate

Neurologic examNeurologic exam Signs of spasticity or hypotoniaSigns of spasticity or hypotonia

Cardiovascular/Lung examCardiovascular/Lung exam


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PhysicalPhysical

Signs of neglect or abuseSigns of neglect or abuse Lack of age appropriate eye contact, smiling,Lack of age appropriate eye contact, smiling,

vocalization, or interest in environmentvocalization, or interest in environment

Chronic diaper rashChronic diaper rash ImpetigoImpetigo

Flat occiputFlat occiput

Poor hygeinePoor hygeine

BruisesBruises

ScarsScars


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Lab EvaluationLab Evaluation

Unless suggested by H&P, no routine labUnless suggested by H&P, no routine labtests recommended initially*tests recommended initially*

One study of hospitalized pts resulted in only 1.4% ofOne study of hospitalized pts resulted in only 1.4% oftests being of diagnostic assistance in FTTtests being of diagnostic assistance in FTT

If problem persists, could consider:If problem persists, could consider: CBC, U/A, Electrolytes, TSH, ESR, Lead, HIV, TbCBC, U/A, Electrolytes, TSH, ESR, Lead, HIV, Tb

If not improving with adequate diet,If not improving with adequate diet,consider:consider:

Stool for fat, reducing substances, pathogensStool for fat, reducing substances, pathogens Celiac antibody testingCeliac antibody testing CF testingCF testing

*(SOR*(SOR B, historical, uncontrolled study, Ref 1, 2)B, historical, uncontrolled study, Ref 1, 2)


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ManagementManagement

Parental behaviorParental behavior

May need reassurance to help with their ownMay need reassurance to help with their ownanxietyanxiety

Encourage, but dont force, child to eatEncourage, but dont force, child to eat Make meals pleasant, regular times, dont rushMake meals pleasant, regular times, dont rush

May need to schedule meals every 2May need to schedule meals every 2--3 hours3 hours

Make the child comfortableMake the child comfortable

Encourage some variety and cover the basicEncourage some variety and cover the basicfood groupsfood groups

Snacks between mealsSnacks between meals


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Do you hospitalize?Do you hospitalize?

Rarely necessaryRarely necessary

Consider if:Consider if: the child has failed outpt managementthe child has failed outpt management

FTT is severeFTT is severe

Medical emergency if wt


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For difficult cases:For difficult cases:

Multidisciplinary team approachMultidisciplinary team approachproduces better outcomesproduces better outcomes

DietitiansDietitians

Social workersSocial workers

Occupational therapistsOccupational therapists

PsychologistsPsychologists NG tube supplementation may beNG tube supplementation may be

necessarynecessary


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Outcomes and PrognosisOutcomes and Prognosis

Persistent disorders of growthPersistent disorders of growth

6 of 7 studies showed statistically6 of 7 studies showed statisticallysignificant persistent poor growth (ht,significant persistent poor growth (ht,wt, hc) in FTT group at up to 5 yearswt, hc) in FTT group at up to 5 yearsfrom initial treatment.from initial treatment.

Earlier intervention leads to better outcomesEarlier intervention leads to better outcomes


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FTT and Immunologic/InfectiousFTT and Immunologic/InfectiousOutcomesOutcomes

FTT children have significantly increasedFTT children have significantly increasedsusceptibility to infectionsusceptibility to infection

Among hospitalized childrenAmong hospitalized children increasedincreasedrates of bacteremia and mortalityrates of bacteremia and mortality

Increased rates of upper and lowerIncreased rates of upper and lowerrespiratory infectionsrespiratory infections


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Concurrent Behavior disordersConcurrent Behavior disorders FTT groups scored lower on reports describingFTT groups scored lower on reports describing

affect and communications skillsaffect and communications skills

Behavior disorders at followBehavior disorders at follow--upup Various trials have demonstrated significantVarious trials have demonstrated significant

increase in behavioral problemsincrease in behavioral problems

Cognitive DevelopmentCognitive Development

There is a consistent association between FTTThere is a consistent association between FTTand lower cognitive development test scores inand lower cognitive development test scores inpreschool and primary school childrenpreschool and primary school children


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TopTop 66 take home pointstake home points

1.1. Evaluation of Failure to Thrive involvesEvaluation of Failure to Thrive involvescareful H&P, observation of feedingcareful H&P, observation of feedingsession, and shouldsession, and should notnot include routineinclude routine

lab or other diagnostic testinglab or other diagnostic testing2.2. Nutritional deprivation in the infant andNutritional deprivation in the infant and

toddler age group can have permanenttoddler age group can have permanenteffects on growth and brain developmenteffects on growth and brain development

3.3. Treatment can usually occur by theTreatment can usually occur by theprimary care physician in the outpatientprimary care physician in the outpatientsetting.setting.


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TopTop 66 take home pointstake home points

4.4. Psychosocial problems predominate asPsychosocial problems predominate asthe causes of FTT in the outpatientthe causes of FTT in the outpatientsettingsetting

5.5. Treatment goal is to increase energyTreatment goal is to increase energyintake to 1.5 times the basalintake to 1.5 times the basalrequirementrequirement

6.6. Earlier intervention may make it easierEarlier intervention may make it easierto break difficult behavior patterns andto break difficult behavior patterns andreduce sequelae from malnutritionreduce sequelae from malnutrition


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Case PresentationCase PresentationFollowFollow--upup

WALSTON, KEIRA

02/579-13-8844

9 -A ug -0 6 2 .7 3 4.2 8 55 .8 8 39 .00

2-Nov-06 5.57 4.93 60.96

0.00

19-May-06 3.69 50.80

21-Aug-06 3. 13 4.68 60.96 41.00

30 -N ov- 06 6 .5 0 5 .1 3

0.00

2 2- Se p- 06 4 .2 0 4.85 60.96 41.00

7-N ov-06 5.73 4.62

31-Oct-06 5.50 4.88 60.96

Received NG tubeReceived NG tubefeeds for approx 2feeds for approx 2weeksweeks

OT worked with ptOT worked with ptto find a nippleto find a nipplethat she wouldthat she wouldtaketake

Wt gain rapidlyWt gain rapidlypicked up in latepicked up in lateNovemberNovember


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michener - failure to thrive

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