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Failure to thrive (FTT) atau Gagal Tumbuh
IKG SuandiDepartment of Pediatrics, School of Medicine
Udayana University/Sanglah Hospital
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Objectives
• Mengetahui definisi dan kriteria pasien dg failure to thrive (FTT) atau gagal tumbuh
• Mengetahui penyebab atau patofisiologi failure to thrive (FTT) atau gagal tumbuh
• Mengetahui cara mencegah atau merujuk pasien dg failure to thrive (FTT) atau gagal tumbuh
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Definition
• Failure to thrive mula-mula pd awal th.1900 dipakai utk menguraikan:– keadaan malnutrisi1 – dan keadaan depresi pd bayi2
• Failure to thrive suatu deskripsi dan bukan menyatakan suatu diagnostik:– pada anak yg BB-nya tidak naik-naik3 – atau peningkatan BB secara bermakna di bawah BB
anak lainnya yg seusia dan berjenis kelamin sama4.
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Table 1. Definitions of Failure To Thrive (FTT)
• Attained growth– Weight < 3rd percentile on NCHS growth chart– Weight for height < 5th percentile on NCHS growth chart– Weight 20% or more below ideal weight for height– Triceps skin fold thickness < 5 mm
• Rate of growth– Depressed rate of weight gain
• < 20 g/d from 0-3 months of age• < 15 g/d from 3-6 months of age
– Fall-off from previously established growth curve• Downward crossing of > 2 major percentiles on NCHS growth chart
– Documented weight loss
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Figure 1. The curve of patient with FTT
Delayed 8 weeks or more
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Figure 2. The curves of patient with FTT
(Weight)
(Height)
(Head circumference)normal
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Etiology(1)
• Faktor-faktor penyebab gagal tumbuh pada bayi dan anak, meliputi:– Penyakit medis yg serius/berat– Disfungsi interaksi antara anak dan pengasuhnya– Kemiskinan – Misinformasi orangtua– Child abuse
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Figure 3. Nonorganic FTT
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Etiology(2)
• Mayoritas kasus penyebabnya bukan penyakit organik; tapi gagal tumbuh sering karena problem psikososial
• Apakah penyebabnya penyakit primer organik atau psikososial anak akan mengalami malnutrisi dg konsekuensi fisik dan psikologik berisiko long-term physical and psycho-developmental squelae.
Etiology(2)Etiology(2)
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Figure 4. Organic etiology (intestinal malrotation)
Abnormal bands
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Figure 5. Pedigree patient with FTT
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Figure 6. Pedigree patient with FTT
Carrier
Unaffected
grand mother or grand father
Carrier grand mother
Unaffected grand father
Unaffected
Unaffected
18 month old Affected
8 year old unaffected
Mr. A Mrs. A
F1 :
F2 :
F3 :
F4 :
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Table 2. Causes of inadequate weight gain
1. Inadequate intake:
Poverty, misperceptions about diet & feeding practices, error in formula
constitution, dysfunctional parent-child interaction, mechanical problems with
suck-swallow-feeding, systemic disease resulting in anorexia/food refusal.
2. Calorie wasting:
Persistent vomiting, mal-absorption and/or chronic diarrhea, renal losses.
3. Increased caloric requirements:
Congenital heart disease, chronic respiratory disease, neoplasm,
hyperthyroidism, chronic or recurrent infection.
4. Altered growth potential/regulation:
prenatal insult, chromosomal abnormality, endocrinopathies.
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Table 3. Factors influencing nutritional inadequacy in the elderly population
Physiologic Pathologic Sociologic Psychologic
Decreased taste Dentition Ability to shop for food Depression
Decreased smell Dysphagia, swallowing problems Ability to prepare food Anxiety
Dysregulation of satiation
Diseases (cancer, CHF, COPD, diabetes, ESRD, thyroid)
Financial status
Low socioeconomic
Loneliness
Delayed gastric emptying
Medication (diuretic, antihypertensive, dopamine agonist, antidepressant, antibiotic, antihistamine)
Impaired activities of daily living skills
Emotionally stressful life events
Decreased gastric acid
Alcoholism Lack of interactions with others at mealtime
Grief
Decreased lean body mass
Dementia Dysphoria
CHF = congestive heart disease; COPD = chronic obstructive pulmonary disease; ESRD = end stage renal disease
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Keys of aspects of the evaluation
• Evaluasi pertumbuhan sekarang dan yg terdahulu:– Riwayat penyakit dan pemeriksaan fisik– Perkembangan / kebiasaan– observasi makanannya– situasi-spesifik dan interaksi global anak-orangtua– Pemeriksaan laboratorium selektif tergantung hasil
pemeriksaan di atas
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Diagnosis(1)
• Bila anak pertumbuhannya buruk fokuskan pada: – Identifikasi gejala dan peny. yg mendasari.– Tingkat beratnya malnutrisi.– Penting mencari tanda-tanda spt. kekerasan fisik
(physical abuse) / terlantar/tidak diinginkan atau tingkah-laku yg menyimpang
• Interaksi orangtua-anak– Perhatikan waktu anak makan cara ini utk
mengidentifikasi tingkah-laku spesifik atau masalah interaksi selama makan.
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Figure 7. Enteropathology of patient with diarrhea and FTT
Abnormal villous & mucosa
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Figure 8. Organic abnormality of a patient with FTT
Abnormal brain
Distended abdomen
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• Perkembangan Psychomotor:– Bila anak gagal tumbuh psikososial berat
manifestasi bermacam-macam dari hyperalert, perhatiannya berlebihan sampai menolak kontak mata dan apathetic withdrawal.
– Beberapa anak manifes perkembangan terhambat, terutama pada area bahasa dan tingkah-laku adaptif sosial tergantung pada stimulasi lingkungan.
Diagnosis Diagnosis(2) Diagnosis(2)
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Figure 9. Patients with FTT
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• Pemeriksaan laboratorium:– Tergantung riwayat penyakit, pem. fisik, data
pertumbuhan, dan peny. organik.
– Studi laboratorium utk menentukan status nutrisi dan masalah anemia defisiensi besi.
– Pemeriksaan Lab.: darah lengkap, serum elektrolit,
serum kreatinin, total protein/albumin, urinalysis, kultur urine, and bone age (bila tinggi badan juga buruk).
Diagnosis(3) Diagnosis(3)
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Management(1)
• Evaluasi dan tatalaksana secara obat-jalan.
• Gagal tumbuh psikososial perlu MRS bila berisiko tinggi, mengalami kekerasan fisik / terlantar, malnutrisi berat atau scr medis tidak stabil, atau tatalaksana obat-jalan mengalami kegagagalan.
• Tatalaksana gagal tumbuh psikososial bersifat individu tergantung kebutuhan spesifik anak dan keluarga.
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• Rehabilitasi nutrisional difokuskan pd upaya mengoreksi:– Interaksi anak-orangtua– Misinformasi orangtua– Tuntunan makanan spesifik– Kebutuhan psikososial keluarga.
• Pendekatan tim multidisiplin:– Meliputi pekerja sukarela / pekerja sosial, nutrisionis,
spesialis perilaku anak, dan community-based outreach services.
Management(2)
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Summary
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