failure to thrive

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Seminar on: Failure to thrive

GROUP – 5

BDU, CMHS C-1 01/01/ 2008 E.C

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ContentsDefinitionOverview of Normal growth patternsEpidemiologyClassification of FTTRisk factorsEtiologiesApproach a child with FTTClinical manifestationsAssessment of FTTWork UPSevere Acute Malnutrition

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Definition

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Definition Failure to thrive (FTT) is a descriptive term applied when a young child’s physical growth is less than that of his or her peers failure to attain the potentials expected for a child of that specific age and sexSign of unexplained Wt lose or poor Wt gainlinear growth and head circumference also may be affected

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Cont’d... common terms to describe FTT; Failure to gain weight Failure to grow Growth deficiency Growth faltering Undernutrition

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Cont’d... Greatest Growth velocity of A Child occurs at ; First 2 years of life & Earliest teens It is at these times that the children most probably fail to thrive.

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Cont’d...

The term FTT is not a disease The best definition for FTT is the one that refers to it as inadequate physical growth diagnosed by observation of growth over time using a standard growth chart

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The most common definition is weight less than the 3rd or 5th percentile for age on more than one occasion, or weight measurements that fall 2 major percentile lines using the standard growth charts of the National Center for Health Statistics (NCHS)

(MEDscape)

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Overview of Normal Growth patterns

Introduction Normal growth is the progression of changes

in height, weight, and head circumference that are compatible with established standards for a given population

The progression of growth is interpreted within the context of the genetic potential for a particular child.

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Term infants: Lose 5-10% of birth Wt, regain by 10-14 days Infant Wt gain pattern:

1kg/mo for the first 3 months 0.5kg/mo from age 3-6 months 0.33kg/mo from age 6-9 months 0.25kg/mo from age 9-12 months

Double the birth Wt by 4-6 mo Triple the birth Wt by 1yr of age

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Cont....d Normal growth is a reflection of overall health

and nutritional status. Understanding the normal patterns of growth

enables Early detection of pathologic deviations (eg, poor

weight gain due to a metabolic disorder, short stature due to inflammatory bowel disease) and

Prevent the unnecessary evaluation of children with acceptable normal variations in growth

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Growth velocity

The change in growth over time, A more sensitive index of growth than is a

single measurement. Current growth points should be compared to

previous growth points, if possible, to determine the interval growth velocity

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Height velocity

Average normal length or height velocities are as follows

0 to 6 months –--- (2.5 cm) per month 7 to 12 months – (1.25 cm) per month 12 to 24 months – (10 cm) per year 24 to 36 months – (8 cm) per year 36 to 48 months – (7 cm) per year 4 to 10 years ------- (5 to 6 cm) per year

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Head Growth

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Head circumference: Average at birth is 35cm 47cm by 1yr of age, rate then slows Average of 55cm by 6 yrs of age

Brain weight doubles by four to 6 months of age and triples by one year of age

The majority of head growth is complete by 4 years of age

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Cont’d... Corrections for gestational age should be made for

premature infant– for weight through 24 months of age, – for stature through 40 months of age, and – for head circumference through 18 months of age

Special growth charts exist for some genetic disorders, such as Down syndrome

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Exception to the definitionChildren with genetically short stature, SGA infants, and preterm infants preterm infants: plot using corrected age

until 2yrs of age if birth Wt > 1000gm until 3yrs of age if birth Wt < 1000gm

Catch-up growth for premature infants: 18mo for HC 24mo for Wt 40mo for Ht

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Epidemiology

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EPIDEMIOLOGY

True incidence of FTT is not knownIn developed nations5–10% of young children 3–5% of children admitted into teaching hospitalsPrevalence higher in developing countries , why? Poverty malnutrition HIV infection

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Cont’d...

Under-feeding is the single commonest cause of FTT

95% of cases of FTT inadequate food peak incidence of FTT the age of 9–24 mo No significant gender difference Majority of children ≤18 months old Uncommon after the age of 5 years

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Risk Factors

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Medical risk factors for FTT include; prematurity Intrauterine growth restriction(IUGR) Developmental delay Congenital anomalies (e.g., cleft lip and/or palate), Intrauterine exposures (e.g., alcohol, anticonvulsants, infection, lead poisoning, anemia) and Any medical condition that results in inadequate intake, increased metabolic rate, maldigestion, or malabsorption

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Psychosocial risk factors for FTT include:PovertyCertain health and nutrition beliefs (e.g., fear of obesity or cardiovascular disease, prolonged exclusive breastfeeding), Social isolation Life stresses Poor parenting skills Disordered feeding techniques Drug or substance abuse Other psychopathology violence, and abuse

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Classification

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Classification

Traditionally, classified as 1.Organic FTT

2○ to underlining medical illnesses Account for less than 20% of cases

2.Nonorganic FTT (NOFT) Psychosocial FTT No known medical condition that causes poor growth Inadequate food or undernutrition Accounts for over 70% of cases

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3 . Mixed FTTOrganic and non organic causes coexist.Those with organic disorders may also suffer from environmental deprivationLikewise, those with severe undernutrition From non-organic FTT can develop organic medical problems

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Cont’d...Based on pathophysiology, FTT may be classified into those due to:

1. inadequate caloric intake 2. inadequate absorption 3. increased caloric requirement, and 4. defective utilization of calories

This classification leads to a logical organization of many conditions that cause or contribute to FTT; which is the preferred classification,

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Etiologies of FTT

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Etiologies

Etiologies of FTT by pathophysiology

1. Inadequate caloric intakeInappropriate feeding technique Inappropriate nutrient intake :

excess fruit juice consumption inappropriate preparation of formula inadequate quantity of food, inappropriate food for age, neglect Inappropriate parental knowledge

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Disturbed caregiver/child relationshipEconomic deprivationInsufficient lactation in mother Mechanical problems (cleft palate, nasal obstruction, adenoidal hypertrophy, dental lesions) Sucking or swallowing dysfunction (CNS, neuromuscular)

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2. Inadequate Absorption or Increased Losses Malabsorption

lactose intolerancecystic fibrosis cardiac disease malrotation inflammatory bowel disease(IBD) milk allergy parasitesceliac disease

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Biliary atresiaCirrhosis Vomiting

Infectious gastroenteritisIncreased intracranial pressure

Intestinal tract obstruction (pyloric stenosis, hernia, malrotation, intussusception) Infectious diarrhoea Necrotizing enterocolitis or short bowel syndrome

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3. Increased Caloric Requirement Hyperthyroidism Malignancy Chronic inflammatory bowel disease Chronic systemic disease (juvenile idiopathic arthritis) systemic infection

Urinary tract infection Tuberculosis Toxoplasmosis

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Chronic metabolic problems HypercalcemiaStorage diseasesInborn errors of metabolism

galactosemiadiabetes mellitus adrenal insufficiency

Chronic respiratory insufficiency bronchopulmonary dysplasiacystic fibrosis

Congenital or acquired heart disease

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CARDIAC Cyanotic heart lesions Congestive heart failure Vascular rings

PULMONARY/RESPIRATORY Severe asthma Cystic fibrosis Cronchiectasis Chronic respiratory failure Bronchopulmonary dysplasia Adenoid/ tonsillar hypertrophy Obstructive sleep apnea

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Organic Causes Of FTT

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GASTROINTESTINAL Pyloric stenosis Gastroesophageal reflux Malrotation Malabsorption syndromes Celiac disease Food allergy

Milk intolerance: lactose, protein Pancreatic insufficiency syndromes (cystic fibrosis) Chronic cholestasis Inflammatory bowel disease Chronic congenital diarrhea states Short bowel syndrome

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… NEUROLOGIC

Cerebral palsy Hypothalamic and other CNS tumors Neuromuscular disorders Neurodegenerative disorders

RENAL Urinary tract infection Renal tubular acidosis Renal failure

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ENDOCRINE Diabetes mellitus Diabetes insipidus Hypothyroidism/hyperthyroidism Growth hormone deficiency Adrenal insufficiency

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GENETIC/METABOLIC/CONGENITAL Sickle cell disease Inborn errors of metabolism (organic acidosis, hyper- ammonemia, storage disease) Fetal alcohol syndrome Skeletal dysplasia Chromosomal disorders Multiple congenital anomaly syndromes (VATER, CHARGE)

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MISCELLANEOUS Collagen-vascular disease Malignancy Primary immunodeficiency Transplantation

INFECTIONS Perinatal infection (TORCH) Occult/chronic infections Parasitic infestation Tuberculosis HIV

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Non-organic FTT (Psychosocial/Behavioral)Commonest CauseInadequate diet because of poverty/food insufficiencyErrors in food preparation Child/parent interaction problemPoor parenting skill (lack of knowledge of sufficient diet/feeding techniques)Food refusalParental mental health/cognitive problems

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Child abuse/neglectFamily dysfunction: marital stress, mental illness, substance abuse, …Infant co-morbiditiesUnintentionalEmotional deprivation

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APPROACH TO A CHILD WITH FAILURE TO THRIVE

1. History Taking Prenatal History

Smocking Alcohol consuming Use of medication Any illness during pregnancy

History

Postnatal History Neonatal asphyxia/Apgar scores Prematurity Small for gestational age Birth weight and length Congenital malformations or infections Maternal bonding at birth Length of hospitalization Feeding difficulties during neonatal period

History Feeding history

Details breast and formula feedingTypical feeding schedule, plus food preparation (formula prep, portion size) Methods of feeding, length of time spent feeding, and diet supplementation/medication Description of type of solid foods taken (quantitative composition and frequency of meals and snacks)Prospective 3-day food diary

HistoryA direct observation- issues of sucking ability, choking, regurgitation, vomiting, and diarrhea, mother’s affect and attitude.

Change in formula, change from breast milk to formula, and changes in the primary individuals responsible for feeding the child

Parents’ attitude about feeding (restrictions of food based on finances, religion

History

HistoryFamily History

stature and growth patterns Medical problems Genetic diseases Developmental delays

History Age and occupation of parents Who feeds the child? Life stressors (loss of job, divorce, death in family) Availability of social and economic support Perception of growth failure as a problem History of violence or abuse of care-giver

Psychosocial HistoryFamily compositionAny major events in the child’s lifeFamily stressors

Chronic Illness, Martial stress Single parenthood Depression Domestic violence Substance abuse, Employment / financial obligations

History

Growth and eating pattern of other siblingsYoung parental ageAffluent circumstances or parents engaged in career developmentChild rearing beliefs

HistoryPoverty, Certain health and nutrition beliefs (eg, fear of obesity or cardiovascular disease, prolonged exclusive breastfeeding),Social isolation, life stresses, Poor parenting skills, Disordered feeding techniques,Substance abuse or other psychopathology, violence, and abuse

2. Physical ExaminationThe four main goals of physical examination include

1. Identification of dysmorphic features suggestive of a genetic disorder that affects growth

2. Detection of an underlying disease that may impair growth

3. Assessment for signs of possible child abuse4. Assessment of the severity and possible effects

of malnutrition

Physical examination General appearance

Cachexia, temporal wasting, sparse hair or alopecia malnutritionDysmorphic features

Small palpebral fissures Midface hypoplasia Flat philtrum Thin vermilion border of fetal alchohol syndrome)

Physical examination

Vital signsTemperature hypothermiaPR tachycardia RR tachypenicBP hypotension

Anthropometry derangements


HEENT Microcephaly Delayed closure of fontanelle Cataracts Papilledema Oropharyngeal lesions (eg, caries, tongue enlargement, mandibular hypoplasia, tonsillar hypertrophy, defects in soft or hard palate) Delayed tooth eruption Thyroid enlargement Thyroid disease


Chest Wheezing Crackles Prolonged expiratory phase Hyperexpansion

AbdomenAbdominal distensionhyperactive bowel soundsHepatosplenomegaly

Physical examination Genitourinary

Genitourinary abnormality Rectal fistulae

Musculoskeletal Bony deformities Craniotabes Beading of the ribs Scoliosis Bowing of the legs or distal radius and ulna Enlargement of the wrist Edema

Physical examination Skin and Mucous Membranes

Pallor Clubbing Scaling skin Spoon-shaped nails Iron deficiency Cheilosis Vitamin deficiency Chronic diaper rash


Neurologic Abnormal deep tendon reflexes Hypotonia Weakness Spasticity Neuropathy

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Red Flag Signs and Symptoms Suggesting Medical Causes of Failure to Thrive

• Cardiac findings suggesting congenital heart disease or heart failure (e.g., murmur, edema, jugular venous distention)• Developmental delay• Dysmorphic features• Failure to gain weight despite adequate caloric intake• Organomegaly or lymphadenopathy• Recurrent or severe respiratory, mucocutaneous, or urinary• Infection• Recurrent vomiting, diarrhea, or dehydration

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Clinical Features

Most common clinical presentation is poor growthAccompanied by physical signs;

AlopeciaReduced subcutaneous fat or muscles DermatitisSyndromes of marasmus or kwashiorkor

Failure to meet expected age norms for ht and wtRecurrent infectionsDepending on the severity infants with FTT may exhibit

Thin extremitiesNarrow faceProminent ribs and wasted buttocks

Cont’d…

Neglect of hygieneDiaper rashUnwashed skin Uncut and dirty finger nails orunwashed clothing

Delays in social and speech development Expressionless face and hypotonic

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Assessment of FTT

Anthropometric criteria:1. A child younger than 2 years of age whose weight is

less than the 3rd or 5th percentile for age on > 1 occasion

2. A child younger than 2 years of age with weight is less than 80% of the ideal weight for age

3. A child younger than 2 years whose weight for age percentile crosses two major percentiles lines on a standard weight curves below a previously established growth rate

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Growth Charts

• Standard growth charts are commonly used to define how the growth of a child compares to normal.

• Growth charts are constructed using a group of normal children living:

– In a given area at a given time.

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Recommended growth chartsWHO growth charts :

For both boys and girls• Weight-for-age• Length-for-age• Head circumference-for-age, and • Weight-for-length

CDC/NCHS growth charts : For both boys and girls• Weight-for-age• Length-for-age• Head circumference-for-age, and • Weight-for-length

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Work Up

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LABORATORY EVALUATION Laboratory evaluation for organic disease should be guided by the signs and symptoms found in the initial evaluation. A careful history and physical examination in the child with failure to thrive (FTT) may suggest clues to an organic disease Laboratory studies that are not suggested on the basis of the initial history and examination rarely are helpful.

One study revealed that only 1.4 % of the laboratory studies performed in evaluating children with FTT were useful diagnostically

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Simple routine tests includes:Random Blood Sugar(RBS)complete blood count(CBC)Urinalysis(U/A)electrolyte levelsstool examPIHCTTB

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Severe Acute Malnutrition

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Child with visible severe wasting

Child with edematous malnutrition

Severe acute malnutrition is defined by a very low weight for height (below -3z scores of the median WHO growth standards), by visible severe wasting, or by the presence of nutritional oedema

one of the most common causes of morbidity and mortality among children under the age of 5 years WW

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– Dx is made based on:

1. In infants < 6 months WFH < 70%(Severe wasting) of NCHS median, OR Bilateral pitting oedema of nutritional origin, OR Visible Severe Wasting if it is difficult to determine W/L

2. children 6 months up to 5 years WFH < 70%(Severe wasting) of NCHS median, OR Bilateral pitting oedema of nutritional origin, OR MUAC <11cm (for infants above 6months or >65cm length)

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Investigation: RBS-------HypoglcemiaCBC--------Hct, HbU/A-------- UTISerum electrolytes---↑Na+, ↓K+stool exam---parasites

chest X-ray-

Blood culturesepsis

HIV test

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Pneumonia ,TB

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THANK YOU

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failure to thrive

Health & Medicine