Transcript failure to thrive

FAILURE TO THRIVE
Sabina A Ali, M.D.
Pediatric Gastroenterology
February 2008
OVERVIEW
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Case
Background
Epidemiology
Definitions
Factors
Diagnosis
Evaluations
Treatment
Conclusion
Cases that confuse
CASE
• 15-month-old girl, born full term, no complications was referred by her
primary care for evaluation of poor growth. She had grown adequately
for the first 6 postnatal months, but her growth began to plateau after
6 months of age. She had experienced nine ear infections over 9
months, several bouts of "pneumonia," and loose bowel movements
and "diarrhea" almost constantly.
• Nutritional history included breastfeeding for 2 months, followed by
weaning to formula. She was started on rice cereal at 4 months of age
and gradually was introduced to a variety of pureed foods. She had
been eating some table food for many months.
• Family history was noncontributory. The parents were very
concerned. The maternal grandmother, who had lived with the family,
had cancer and was in hospice care. The mother reported depression
because of her own mother’s illness. The parents had separated for
several months during the last year, but were back together and doing
well.
• Physical examination included thin, wispy hair; bilateral serous otitis
media; transmitted upper airway rhonchi; and a protuberant abdomen.
She was normocephalic, her length was at the 10th percentile, and her
weight was below the 3rd percentile . She had very thin extremities.
GROWTH CHART
INTERVENTION
BACKGROUND
• Early reference to an infant who "ceased to
thrive" can be traced to the initial edition of The
Diseases of Infancy and Childhood by L. Emmett
Holt in 1897.
• Holt equated infantile wasting conditions with
malnutrition, although he clearly recognized that
this could be associated with a variety of clinical
circumstances.
• The phrase "fail to thrive" first seems to have
appeared in print in 1933 in the 10th edition of
that classic text.
EPIDEMIOLOGY
• Prevalence has been reported as 1-5% of
all pediatric referrals to pediatric hospitals
• 10-20% of all children who are treated in
ambulatory care settings.
DEFINITION
DEFINING FAILURE TO THRIVE CAN BE DIFFICULT
3rd percentile vs 5th percentile
2 standard deviations, 5th percentile
2.2 standard deviations, 3rd percentile
DEFINITION
• Is a symptom rather than a disease or
diagnosis.
• Weight (or weight for height) is more than
2 SD below the mean for age and sex.
• A child whose weight curve has crossed
downward more than 2 major percentiles.
• Calculate z scores (research use).
MEASUREMENTS
• Measure all three- weight, height and head
circumference.
• In a child younger than 2 years , the recumbent length
rather than the standing height is obtained.
• Correct plotting and using correct NCHS graphs is
essential – Correct for gestational age until:
• 18m for head circumference
• 24m for weight
• 40m for stature
• When all are decreased the incidence of organic disease
is about 70%.
NCHS (National Center for Health Statistics).
NORMAL GROWTH
• An understanding of abnormal growth
requires a review of normal growth
patterns
• “Patterns of progression in weight and
height that is consistent with the
established standards for age”.
So, What’s Normal?
 Infants should regain their birth weight by 2 weeks (15-30
g per day)
 Length: Increases 25 cm in first year
 HC averages 35 cm birth to 47 cm at 1 year
AGE
MEAN DAILY WEIGHT GAIN
0-3 M
25-30 g
3-6 M`
17-18g
9-12 M
10 g
1-3 Y
7-10 g
4-6 Y
6g
OTHER DEFINITIONS
• WASTED: A decreased weight for age and
weight for height with a normal height for
age.
• STUNTED: A decrease height for age and
weight for age with a normal weight for
height.
Major Anthropologic Categories of FTT.
WEIGHT
HEIGHT
HC
TYPE I
NOR
Malnutrition of organic or
non-organic etiology
TYPE II
NOR
Endocrine, bony dystrophy,
Constitutional short stature
TYPE III
Chromosomal, metabolic,
severe malnutrition
HC: Head Circumference
NORM: Normal
ETIOLOGY
• 2 BIG categorize but large differential pool.
ORGANIC
MIXED
INORGANIC
CLASSIFICATIONS
• The differential diagnosis of failure to thrive is very
broad
• Historically, the etiologies of failure to thrive were
grouped as organic and nonorganic.
• Organic failure to thrive refers to a major disease
process or a single or multiple organ dysfunction.
• Nonorganic failure to thrive suggests insufficient
emotional or physical nurturing without distinct
pathophysiologic abnormality.
• Some have suggested that there is mixed failure to
thrive.
CLASSIFICATION
More useful classification system is
Malnutrition
&
FTT
Inadequate
Caloric Intake
Malabsorption
Excessive
Caloric
Expenditure
FAILURE TO THRIVE
Psychosocial
Nutritional
Kwashiorkor
Marasmus
Zinc/iron deficiency
Feeding disorders
Oral-motor apraxia
Cleft palate
Dentitions
GI
Vomiting
Gastroesophageal reflux
Structural anomalies
Central nervous system lesion
Diarrhea
Chronic toddler diarrhea
Infectious
Malabsorption
Celiac disease
Inflammatory bowel disease
Hepatic
Chronic hepatitis
Glycogen storage diease
Infectious
Tuberculosis
Human immunodeficiency virus
Pulmonary
Tonsillar hypertrophy
Cystic Fibrosis
Cardiac
Other chronic diseases
Renal
Chronic pyelonephritis
Fanconi syndrome (and variants)
Chronic renal insufficiency
Endocrine
Hypothyroidism
Rickets
Viitamin D deficiency
Vitamin D resistance
Central nervous system lesion
Hypophosphatemic
Growth hormone deficiency/resistance
Growth hormone deficiency/resistance
Hypercortisolism
Pseudohypoparathyroidism
Type I diabetes mellitus (poorly controlled,
Mauriac syndrome)
Central nervous system
Pituitary insufficiency
Diencephalic syndrome
Oncologic
Calories, Calories,……
• Root of growth failure stems from
• inadequate calories
• – Inadequate intake
• – Increased demands
• – Poor absorption
• Infants require approximately
110-120 kcal/kg/day
At age 1 year, 100 kcal/kg/day
CALORIC INTAKE
• Inadequate Caloric Intake
– Incorrect preparation of formula
– Poor feeding habits (ex: too much
juice)
– Poverty
– Mechanical feeding difficulties
(reflux, cleft palate, oro-motor
dysfunction)
– Neglect
Consider child abuse and neglect in cases of
FTT that don’t respond to appropriate
interventions
Inadequate absorption
– Celiac disease
– Cystic fibrosis
– Milk allergy
– Vitamin deficiency
– Biliary Atresia
– Necrotizing enterocolitis
Increased metabolism
– Hyperthyroidism
– Chronic infection
– Congenital heart disease
– Chronic lung disease
• Other considerations
– Genetic abnormalities, congenital infections,
metabolic disorders (storage diseases, amino
acid disorders)
EVALUATION
• Accurately plotting growth charts at every
visit.
• Use correct growth charts!
• Evaluate the trends
• History and Physical more important than
labs
Examination: Key Points
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Infant eye contact (if avoids may be abuse)
Poor suck or motor skills
Watch caretaker feed the infant!!!
Plot height, weight and head circumference
Dysmorphic features
Lung or heart exam
Skin: scars, jaundice, eczema, bruises or rash
COMPREHENSIVE NUTRITIONAL
ASSESMENT
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Dietary history
Medical and medication history
Physical examination
Growth and anthropremetric measurements
Laboratory tests.
HISTORY
• Pregnancy/Birth
LBW, IUGR, prematurity, postnatal complications, tube
feeding. Substance abuse? postpartum depression?
• Dietary type of food, time spent over meal, number of
meals, self feed, formula/supplements, unusual feeding
behavior, who feeds?
• Past medical history
Illnesses, hospitalizations, reflux, vomiting, stools, difficulty
swallowing
• Social
Who lives in the home, family stressors, poverty, drugs?
• Family
Parental height, siblings, Medical condition (or FTT) in
siblings, mental illness, stature?
DIETARY HISTORY
• Assess methods of feeding
• breastfeeding patterns (including maternal diet use
of medications that can affect milk production and
let-down such as alcohol or diuretics)
• formula preparation
• volume consumed
• feeding techniques.
• Caloric counts- food diary
• A detailed history of formula preparation :may
reveal a dilute formula that contains insufficient
calories and excess water.
Dietary Associations With Poor
Growth in Young Children
– Breastfeeding difficulties
– Improper formula mixing
– Poor transition to food (6 to 12 months of
age)
– Excessive juice consumption
– Avoidance of high-calorie foods
INVESTIGATIONS
• Lab tests should be guided by H&P.
• Less than 2% of the lab studies performed
in evaluating children with FTT were
useful.
Sills RH AM J Dis Child 1978
INVESTIGATIONS
HISTORY AND
PHYSICAL
FIRST LINE
CBC
ESR, CRP
UA/Cx,
Cr, glucose,
Ca
Thyroid
functions
Sweat Chloride
Celiac serology
(age)
SECOND LINE
Serum AA
Lead level
Ur organic acids
LFTs
PPD
Abd US
CXR
Head US
EKG/Eho
MANAGEMENT
• Goal is “catch-up” weight gain
• Most cases can be managed with nutrition
intervention and/or feeding behavior modification
• General principles:
– High Calorie Diet
– Close Follow-up
• Keep a prospective feeding diary-72 hour
• Assure access to WIC, food programs, other
community resources
CALORIC REQUIREMENT
• To determine caloric requirements for
infants :
• RDA for age (kcal/kg) x ideal weight for
height (kg)/actual weight (kg)
INTAKE
• Energy intake should be 50% greater than
the basal caloric requirement
• Concentrate formula, add rice cereal to pureed
foods
• Add taste pleasing fats to diet (cheese, peanut
butter, ice cream)
• High calorie milk drinks (e.g Pediasure has 30
cal/oz vs 19 cal per oz in whole milk)
• Multivitamin with iron and zinc
• Limit fruit juice to 8-12 oz per day
WHEN TO HOSPITILIZE
• Do you hospitalize?
– Rarely necessary
– Consider if:
• the child has failed output management
• FTT is severe
– Medical emergency if wt <60-70% of ideal wt
– Hypothermia, bradycardia, hypotension
• safety is a concern
HOSPITILIZATION
• For difficult cases:
– Multidisciplinary team approach produces
better outcomes
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Dietitians
Social workers
Occupational therapists
Psychologists
– NG tube supplementation may be necessary
Hospitalization
• In 1988, Frank and Zeisel reported that 3% to 5% of admissions to
academic pediatric medical hospitals were for failure to thrive.
• At this author’s regional pediatric referral center, 3.9% of inpatient
admissions from November 1998 to October 1999 carried failure to
thrive as a discharge diagnosis.
• Berwick et al demonstrated that the diagnostic yield of hospitalization
was not cost-effective.
• They found that only 0.8% of all tests demonstrated an abnormality
that contributed to an underlying diagnosis.
• On their review of the inpatient records of 122 infants who had
unexplained failure to thrive by ages 1 to 35 months, approximately
33% had no diagnosis following the evaluation, 32% had a social or
environmental etiology, and 31% were given a specific physiologic or
organic diagnosis.
• Of this latter group, 66% had gastroesophageal reflux or nonspecific
diarrhea.
HOSPITILIZATION
Mainstay of management if the child is refractory to the previously
mentioned outpatient procedures.
• Hospitalization has little impact (other than increasing costs) on the
diagnostic categorization of failure to thrive.
• Management may be enhanced during a hospitalization.
• Hospitalization of an infant who has failure to thrive allows timely
input from important ancillary health-care staff, including nutritionists,
social workers, occupational and physical therapists, therapeutic
recreation workers ("child life specialists"), behavioral and
developmental specialists and psychologists, and bedside nurses.
• A hospitalization of 10 to 14 days or greater with adequate caloric
intake commonly is believed to be sufficient to demonstrate
appropriate weight gain.
• Unfortunately, it has become clear in today’s medical environment that
third-party payers are reluctant, if not sometimes refusing, to authorize
hospitalization for the evaluation and treatment of failure to thrive.
• Practitioners scrutinized their diagnostic evaluation of such children or
performed key diagnostic studies on an outpatient basis.
TAKE HOME POINTS
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Evaluation involves careful H&P, observation of feeding
session, and should not include routine lab or other
diagnostic testing
Nutritional deprivation in the infant and toddler age
group can have permanent effects on growth and brain
development
Treatment can usually occur by the primary care
physician in the outpatient setting.
Psychosocial problems predominate as the causes of
FTT in the outpatient setting
Treatment goal is to increase energy intake to 1.5 times
the basal requirement
Earlier intervention may make it easier to break difficult
behavior patterns and reduce sequelae from
malnutrition
TAKE HOME POINTS
 Accurate plotting is essential
 Most important evaluation is H&P
 Dietary history and social milieu
are important clues.
 Key is to observe family/infant
Interactions.
 Selective labs may be useful.
 Catch up growth requires
increased calories, and there are
many ways to achieve this
CASE FOLLOW UP
• Laboratory studies were ordered and a sweat test
scheduled.
• The family was asked to feed her three meals and three
nutritious snacks on a set daily schedule.
• The importance of social support for the family dealing
with a sick child, a fragile marriage, and a dying
grandmother was discussed, and the family was helped
to contact community mental health services. Telephone
contact was maintained.
• Laboratory studies: showed anemia, a low serum
albumin, and positive tests for celiac disease. These
positive tests were confirmed by an intestinal biopsy
diagnostic for celiac disease. Her sweat test was
negative. She responded to a gluten-free diet with
excellent weight gain.
DIAGNOSED WITH CELIAC DISEASE
AND GLUTEN FREE DIET STARTED
CASE
• In this case, the important psychosocial problems were
not the cause of the child’s FTT.
• These issues may have delayed her diagnosis by
distracting the family from her symptoms or biasing her
pediatricians against a medical cause for her poor
growth.
• On the other hand, she was diagnosed at a young age,
and she made an excellent recovery after the proper diet
was instituted.
• The important clues for an underlying medical condition
included the history of recurrent infections, physical
findings consistent with severe malnutrition, and a height
percentile decreasing nearly simultaneously with the
decreasing weight percentile.
CONDITIONS THAT CONFUSE
WITH FTT
Familial Short Stature:
Genetically determined
Final Height consistent with mid-parental height
Child maintains a growth curve appropriate for the
family without deviation to a lower percentile.
Constitutional growth delay:
Usually present with deceleration of growth in the
first 2 years of life. Delay in bone age and family
history of delayed growth and puberty makes the
diagnosis more likely.
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THANK YOU