Transcript Failure to thrive

Failure to thrive
Diagnostic criteria and diff dx
H and P key points
Dx testing in the evaluation
18 month female
difficulty gaining weight
• 2 previous visits, noted to have slowing in
her weight gain
• Weight previously followed 75% slipped to
50 th
• This visit wt below the 5 th percentile for
age
• Ht has continued along the same 50 th %
trajectory
Scope of the problem
• FTT used to describe children with poor
growth; serial measurements of wt, ht, ofc
compared with population growth
averages
• Growth over time helpful; constitutional
delay children may grow consistently
below (but parallel) curves
• Wasting refers to deficit in wt to ht or type
1 FTT
The broad criterion
• Decrease in wt, ht or ofc percentiles that
crosses 2 major trajectories in downward
trend
• Weight for length below the 5th percentile
(in absence of serial measurements)
• Decreased mid-arm circumference-tohead circumference ratio
• Weight below the 5 th percentile
Non-organic causes
• Family dysfunction (divorce, spousal abuse,
chaotic family style)
• Parental dysfunction (psychosis, drug or alcohol
abuse)
• Parent-child interaction dysfunction
• Isolation or lack of support (no family or
extended family)
• Lack of preparation for parenting or ignorance
• Child abuse/neglect
• Unusual food fad diet
Organic causes of FTT
• Decreased caloric intake
poor feeding (neuro/feeding disorders)
decreased appetite (chronic disease)
vomiting (gerd, ps, icp)
chronic infection (giardea,etc)
mucosal abnormalities (celiac, ibd)
pancreatic insufficiency (cf, etc)
enzyme deficiencies
allergic gastroenteropathy
Furthermore
• Increased losses and
metabolic disorders
protein losing
enteropathy
metabolic
disorders
bile salts def
lympangiectasia
• Increased caloric
requirments
Hyperthyroidism
Chronic diseases:
chd, chronic resp
disease,
malignancy, ibd,
immunodeficiency
With apologies for the list
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Parents and child interact warmly in office
Family hx noncontributory
Diet reasonably varied, good quantity
Parents are stable, good mental health, no
drugs or abuse suspected
History and physical
• Gives direction to the work; AJDC study of
details the futility of investigations unless
suggested in the h and p evaluation
• 3 day diary always helpful in the history to
corroborate the adequacy of caloric intake
• Stool consistency may indicate malabsorption
(malodorous, foamy, floating for fat
malabsorption)
• Vomiting hx directs toward broad differential
Physical exam
• Malnutrition: hair texture and color, skin
• Respiratory: lung sounds, clubbing
• Heart disease: murmurs, PMI heave,
sweaty babies
• GI dis: inc L/S, perianal disease, guiac
• Neuro: wasting, abnl tone
The history continues
• Parents report pt is comfortable, 3 loose
stools a day
• FT, SVD, 3750 gm.
• Breast to 6 months then formula; baby
foods at 5 months; good mix of table foods
• No sig infections, no hosp
• Northern european descent; neg fam hx
The asthenic toddler
• Thin child in no distress
• General exam is normal
• Abdomen is soft nontender; perhaps
slightly distended
• Neuro reveals interactive child, wiry, nml
tone, nml reflexes
• The 3 days diary
gives detailed
account of foods and
milk
• Look for excessive
fluid intake,
inappropriate milk or
juice intake
• Basic labs: CBC,
ESR, chem 7 (bun/cr,
CO2), TPro
• As indicated: stool fat,
occult blood, white
cells, O&P or elisa for
giardia
• As indicated: sweat,
HIV, TB skin test
H & P: loose stools??
• The loose stools raises suspicion for
infection and/or malabsorption
• Stool for O & P, elisa giardia, fecal fat,
white cells
• Sweat chloride and celiac antibodies
Los resultados
• Celiac panel is positive
• Transglutaminases (if ordered) 195 units
(0-20 nml range)
• Antiendomysial antibody is pos at 1:40
(nml less than 1:20)
Celiac disease
• Production of local and systemic
antibodies
• Ig A antireticulin Ab and IgA
antiendomysial Ab are specific markers for
celiac disease
• Tissue transglutaminase Ab has recently
been identified as the autoantigen
recognized by endomysial Ab (most
sensitive marker)
Referral to GI
• Esophagogastroduodenoscopy
• Bx of small bowel consistant with celiac
disease
Celiac disease
• Intolerance to gluten of wheat, barley, rye,
and oats
• More common in whites, nearly
nonexistent in Africa, Asia
• 1:300 in western Ireland, 1:5000 in
Minnesota, 2 % in Sweden and 1 in 50 in a
high risk population (GI clinic waiting
room)
More??
• Familial tendency follows polygenic inheritance
• Strong association between celiac dis and HLA
antigens
• Interaction between genetics and environmental
exposure
• Wheat gluten is water insoluble protein left after
starch extraction
• Gliadin, a complex protein, is a fraction of the
wheat gluten
• T cell response to gluten in the lamina propria
Utility of endoscopy and Bx
• Small bowel mucosal flattening
• Lymphocytic infiltration in lamina propria,
elongation of the crypts, villous atrophy
Treatment of Celiac
• Mainstay is avoidance of gluten
• Quite difficult to achieve in typical Western
diet
• Catch up growth can be rapid and
complete in 15 months after effective
avoidance
Sweaty babies
• 10 week old male with poor weight gain
• Sweaty babies suggests adrenergic
overdrive
• Gallop rhythm, heavy PMI
• Liver edge is down
• Radiograph of chest
6 month comes pale and below 5 th
percent
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Renal lesions are “occult”
Bilateral abdominal masses
Cr 5.8
Posterior urethral valves
Is it a real condition?
• 15 month old female falls off the curves
• CO2 12 on first determination; 15 on
repeat
• Proximal absorption defect seen in toddler
years
• Responds to large doses of bicarb (10 per
kg divided)
• Appetite improves and weight gain is seen
Newborn screening
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6 month old comes in with weight down
She appears puffy
Rsv then chronic congestion
T Pro depressed
False negative from NB screen