Failure to thrive

Dr.Saravanan mahendraFMS Trainee 2012/2013University Kebangsaan Malaysia

OverviewObjectiveDefinitionsIntroductionDiagnosisTreatmentOutcomeApproach Short statureCase presentationTake Home message

ObjectiveAttain sufficient knowledge and skills to recognize and manage children with problems in nutrition and feedingDefinitionFailure to thrive :Weight below the 3rd or 5 th centile for age on more than one consecutive occasionWeight drops down two major percentile linesOthers :Weight less than 80% of the ideal weight for ageBelow 3rd or 5h percentile on the weight for length curve

IntroductionFTT is not a diagnosis/syndrome rather a sign that a child is receiving inadequate nutrition for optimal growth and developmentalUsually describes failure to gain weight In more severe cases length and head circumference can be affectedCauses tend to be multi-factorial and often involve problems with diet and feeding behaviour

Specific infant populations-Premature/IUGR weight may be less than 5th percentile, but if following the growth curve and normal interval growth then FTT should not be diagnosedModified growth charts exist for specific populations such as Down, Turner and Williams syndrome

IntroductionHistorically has been divided into organic and nonorganic causesMost cases have mixed etiologiesThis classification system is out of favorMore useful classification system is:Inadequate caloric intakeInadequate caloric absorptionIncreased caloric requirements

Inadequate Caloric IntakeNot enough food offeredFood insecurityPoor Knowledge of child's needsPoor Transition to table foodAvoidance of high calorie foodsFormula dilutionExcessive juiceBreast feeding difficultiesNeglect / AbuseInadequate Caloric intake.Child not taking enough foodOromotor dysfunction Developmental DelayBehavioural Feeding problemAltered oromotor sensitivityPain and conditioned aversionEmesisGERDMalrotation with intermittent volvulusIncreased Intracranial PressureInadequate Caloric absorptionCystic FibrosisCeliac DiseaseFood Protein insensitivity or intolerance Cow milk protein allergyLactose intoleranceIncreased Caloric Requirement Insulin Resistance (ex: IUGR)Congenital infection (ex: HIV,TORCH)Syndrome (Down, Russell-silver,,Turneer)Chronic disease CardiacRenalendocrineDiagnosisAccurately plotting appropriate growth charts (WHO / CDC chart ) < 6 month : Not more than monthly6 -12 month : 2 montly> 12 month ; 3 monthlyAt every visit recommended or whenever parents concern ariseAssess the trendsHistory taking and physical examination are more important than laboratory testMost cases in primary care setting are psychosocial or nonorganic in etiology

Standard growth chart ?WHO (World Health Organization ) charts:Standard growth chart which describe how healthy children should grow under optimal conditionSuch optimal conditions :High socioeconomic statusSingleton mothersBreastfeedingNo smoking CDC (Central Disease Control) charts0-2 years : use WHO growth standards2 years + : use CDC growth chartsBreastfeedingEver BreastfedBreastfeeding at 3 monthWHO charts100%75%CDC charts50%33%Present US data75%58%WHO versus CDCIn the first few months of lifeWHO curves show a faster rate of weight gainUse of the WHO chartsIncrease in the misperception of poor growth in formula fed infantsAfter 3 monthsWHO curves show a slower rate of weight gainUse of the WHO chartsMight identify formula fed infants as gaining weight too quickly

History takingDietary Keep a food diaryIf formula fed, is it being prepared correctly?When, where, with whom does the child eat?PMHIllnesses, hospitalizations, reflux, vomiting, stools?SocialWho lives in the home, family stressors, poverty, drugs?FamilyMedical condition (or FTT) in siblings, mental illness, stature?Pregnancy/BirthSubstance abuse? postpartum depression?

PhysicalAccurate measurement of childs height, weight, head circumference and plot in the appropriate chartEvaluate for dysmorphic featuresMouth, palateNeurologic examSigns of spasticity or hypotoniaCardiovascular/Lung exam

PhysicalSigns of neglect or abuseLack of age appropriate eye contact, smiling, vocalization, or interest in environmentChronic diaper rashImpetigoPoor hygeineBruisesScarsPhysicalObserve parent-child interactionsEspecially during a feeding sessionHow is food or formula prepared?Oral motor or swallowing difficulty?Is adequate time allowed for feeding?Do they cuddle the infant during feeds?Is TV or anything else causing a distraction?

Lab EvaluationUnless suggested by history and physical examination suggestive, no routine lab tests recommended initially :

One study of hospitalized pts resulted in only 1.4% of tests being of diagnostic assistance in FTT

Laboratory investigation

ManagementGoal is catch up or increase weight gainMost cases can be managed with nutrition intervention and/or feeding behavior modificationGeneral principles:High Calorie DietClose Follow-upKeep a prospective feeding diary-72 hourAssure access help to social welfare and child protector if needed

ManagementEnergy intake should be 50% greater than the basal caloric requirement Concentrate formula, add rice cereal to pureed foodsAdd taste pleasing fats to diet (cheese, peanut butter, ice cream)High calorie milk drinks (Pediasure has 30 cal/oz vs 19 cal per oz in whole milk)Multivitamin with iron and zincLimit fruit juice to 8-12 oz per day

ManagementParental behaviorMay need reassurance to help with their own anxietyEncourage, but dont force, child to eatMake meals pleasant, regular times, dont rushMay need to schedule meals every 2-3 hoursMake the child comfortableEncourage some variety and cover the basic food groupsSnacks between mealsManagementHospitalization ?Rarely necessaryConsider if: the child has failed outpatient management FTT is severe Medical emergency if wt