Transcript (FTT). - muhadharaty.com

♣ definition
:-
-physical growth that is
significantly less
than that of peers .
weight
length
Weight
Head
circumference
height
Does all these parameters fall at one time ?
► in children FTT, malnutrition initially results in
wasting (deficiency in weight gain) ,
► stunting (deficiency in linear growth) generally
occurs after months of malnutrition ,
►head circumference is spared except with chronic
severe malnutrition
♣ Classification :-
Organic
FTT
• Growth failure that is due to an acute or
chronic Disorder that interfere with
nutrient intake, absorption, metabolism,
excretion or that increases energy
requirements .
• Up to 80% of children with growth failure
non- organic do not have an apparent organic disorder;
• Growth failure occurs because of
FTT
environmental neglect (e.g. lack of food ),
stimulus deprivation or both .
Causes of organic failure to thrive
Mechanism
disorder
Decrease nutrient intake
Cleft lip or palate, cerebral palsy,
gastroesophageal reflux, pyloric stenosis
malabsorption
Celiac disease, cystic fibrosis
Inflammatory bowel disease
Impaired metabolism
Galactosemia, fructose intolerance
Down syndrome and turner syndrome
Increase excretion
Diabetes mellitus, proteinuria
Increased energy requirements
Infections, heart failure, hyperthyroidism
Non organic failure to thrive
- Its due to poverty, psychosocial problems in the family,
improper formula preparation, improper mealtime
environment, unusual parental nutritional beliefs .
♣ Review of systems
Clues to organic diseases
1.respiratory
( Dyspnea, Cough, Sputum, Hemoptysis )
Cystic fibrosis
►lungs :Decrease mucociliary clearance result in build up mucus
within the bronchial tree causing airway obstruction and superadded
infection
►increase mucus that obstruct the ducts of the exocrine glands which
produce the digestive enzymes, causing malabsorption.
2.Cardiovascular
( Dyspnea, orthopnea, cyanosis, palpitation )
congenital heart disease
►hypoxia and breathlessness may lead to feeding problems
.
►peripheral anoxia and acidosis may lead to insufficient utilization
of nutrients.
►increase basal metabolic rate that require increase energy intake.
3.Gastrointestinal
(Decrease appetite, chronic diarrhea, chronic
constipation, abdominal distention, vomiting )
celiac disease
.
►autoantibodies cause damage to the villi result in
malabsorption .
4.Genitourinary system
( oliguria, hypertension, headache,
nausea and vomiting )
chronic renal failure
► creating an imbalance of sodium, potassium, and acid-base levels in
the blood, also called acidosis. When blood is not balanced, the body
slows growth to focus energy on restoring the balance.
►decreasing appetite, nausea, vomiting .
►decrease production of erythropoietin so the child develop anemia.
5.Nervous system
( seizures, intellectual impairment, abnormal posture,
abnormal movement, communication and behavior
difficulties )
cerebral palsy
►Unable to suck, swallow or chew .
prenatal
Delivery, postnatal
1.General obstetrical history
1.Neonatal asphyxia
2.Prematurity
3.Birth weight
4.Congenital malformations
or infections
5.Breast feeding support
6.Feeding difficulties
during neonatal period .
2. Recurrent miscarriages
3.Use of medications, drugs,
cigarettes.
Nutritional history
●
Details of feeding (breast feeding or formula feeding,
formula preparation, volume consumed, who feeds the
infants, position and placement of the infant for feeding,
timing and introduction of solids, stool or vomiting
patterns associated with feeding, strength of suck.
Accurate measurement of caloric intake )
●Vitamin
and mineral supplements
●Weaning and introduction of solid food
● food likes and dislikes, allergies
Family history
●family history of failure to thrive in previous sibling
●family history of congenital diseases.
Social history
●source of water supply
general examination :1.degree of malnutrition .
2.dysmorphic features may suggest genetic cause.
3.clues for psychosocial etiology .
4.signs of possible child abuse ( skin rash, injuries,
fractures ) .
5.signs of parents neglect ( neglected hygiene,
diaper rash, unwashed skin, dirty fingernails ).
6.vital signs
7.growth chart
systemic examination
♦ Suggested by the
Tests :1.complete blood count (cbc)
2.serum electrolytes
3.urinalysis and urine culture .
4.hormone studies, include thyroid function test
5.x-ray to determine bone age .
.
♦ other investigations done according to the history and
examination :►cystic fibrosis
-sweat test (sweat chloride > 60 mmol/L).
►celiac disease
-tTG-IgA (anti-tissue transglutaminase antibody)
- small intestine biopsy to confirm the diagnosis.
►congenital heart disease
-echocardiography
►chronic renal failure
- RFT, ultrasound, VCUG, biopsy .
►cerebral palsy
-CT, MRI, DTI(diffusion tensor imaging), FT(fiber tractography)
guidelines :1.improve the child's diet and eating pattern .
2.improvement in the care-givers skills .
3.treat the underlying disease .
4.regular and effective follow up .
admit or not :►children with mild malnutrition can be managed
by the primary care physician in the outpatient setting .
►children with severe malnutrition require
hospitalization for evaluation and proper treatment .
diet and eating pattern :● children with FTT may require more than 1.5 times the
expected calorie and protein intake for their age for
catch-up growth .
● children with FTT who are anorexic may not be able to
consume this amount of food and require energy-dense
foods .
● for formula-fed infants, the concentration of formula can
be changed from 20 cal/oz to 24 or 27 cal/oz
●for toddlers adding butter, oil, peanut butter, or other highcalorie foods .
●In addition, vitamin and mineral supplementation is
needed, especially during catch-up growth .
follow up :● the first priority is to achieve an ideal weight-for-age .
● the second goal is to attain a catch-up in length
expected for the child age .
● depend on the severity of malnutrition initiation of catchup growth may take 2 weeks .
● for children with chronic, severe malnutrition, many
months are needed to reverse all trends in growth .
● Although many children with FTT eventually reach
normal size, they continue to be at risk for developmental,
learning, and behavioral problems .
1.malnutrition-infection cycle
2.refeeding syndrome
3.psychsocial short stature
Malnutrition-infection cycle
:-
-malnutrition causes defects in host defenses. Conversely,
infection increases the metabolic needs of the patient and is
often associated with anorexia. Children with FTT may
suffer from a malnutrition-infection cycle, in which
recurrent infections exacerbate malnutrition, which leads to
greater susceptibility to infection. Children with FTT must
be evaluated and treated promptly for infection and followed
closely .
refeeding syndrome :- etiology:- during starvation, the body slows the metabolic
processes and growth to minimize the need for nutrients,
also the body maintains homeostasis and normal serum
concentration of electrolytes. With rapid reinstitution of
feeding fluid and electrolyte homeostasis may be lost.
-these changes may include :fluid retention,
hypophosphatemia, hypomagnesaemia, hypokalemia .
-can result in life-threatening cardiac, pulmonary, or
neurological problems .
-can be avoided by slow institution of nutrition, close
monitoring of serum electrolytes during initial days of
feeding, and proper replacement of depleted electrolytes.
Psychosocial short stature
-children who live in psychosocial deprivation develop short
stature .
Etiology : endocrine dysfunction is often identified in affected
children, who may have decrease growth hormone secretion and
muted response to exogenous growth hormone.
-Signs and symptoms : polyphagia, polydipsia, vomiting .
The affected children are often shy and passive and are typically
depressed and socially withdrawn.
-treatment : removal of the child from the adverse environment
result in rapid improvement in endocrine function and subsequent
rapid somatic and pubertal growth of the child.
Case study :-A 20-month-old boy presented to his primary physician
with a history of failure to thrive. He was born full term at
3.1 kg and was breast-fed, with diet advanced to solids at
appropriate times. Poor weight gain was first noticed around
9 months. At that time, a complete blood count (CBC) was
normal, as were electrolytes, liver enzymes, and thyroid
stimulating hormone. Stool cultures for bacteria were
negative, and ova and parasites were not done. Feeding
practices were reviewed, and the home environment was
assessed. At 12 months, the child’s diet was supplemented
with PediaSure, due to continued poor growth. He
experienced a slight, but transient improvement in growth
rate. Consequently, he was referred to gastroenterologist.
-By history, the child was an active boy, he had a good
appetite and enjoyed all table foods. There was no history of
vomiting or diarrhea. He passed three to four large stools
per day, which smelled quite badly. He did not attend day
care and the family had no pets. His parents were nonconsanguineous . He had a 10-year-old healthy brother who
was growing properly. However, his brother had been
treated for a Giardia infection several years ago. The family
lived in a rural community and use municipal water for
drinking.
-Examination revealed normal vital signs, a weight of 8.9
kg (significantly below the 5th percentile) and a height of
82 cm (25th percentile).
-His physical examination revealed a small, but adequately
nourished child, with clear lungs, no cardiac murmurs, a
soft, mildly protuberant abdomen without masses nor
organomegaly, normal bowel sounds, and no cutaneous
lesions. Laboratory tests revealed a normal CBC,
erythrocyte sedimentation rate (ESR), electrolytes, liver
function test, total protein, albumin, and a normal urinalysis.