Failure to Thrive

1. Failure to Thrive Dr Usha Mallinath Dr Richard Mones

2. Definition • Wt below 3 rd centile • Wt drops 2 major centiles • Wt for length below 3 rd centile • Wt < 80% ideal wt for age

3. Historic classification • Organic: those for which there is a clear genetic, medical, or anatomic etiology, a very large differential • Nonorganic: insufficient emotional or physical nurturing without pathophysiological abnormality

4. Calories, Calories • Root of growth failure stems from inadequate calories • Inadequate intake • Increased demands • Poor absorption • Infants require approximately110-120 kcal/kg/day • At age 1 year, 100 kcal/kg/day

5. Normal Weight Gain

6. Epidemiology • 1-5% tertiary hospital referrals • 5% in 2006 in USA , CDC • High incidence poverty, low socio-economic status • 50% not identified by health care professions • Non organic FTT common in females

7. Pathogenesis • Insufficient food intake • Increase Energy Requirement • Malabsorption

8. Pathogenesis Insufficient food intake • Inadequate amount of food provided or available • Structural causes of poor feeding e.g. cleft palate, Treacher-Collins • Anorexia of chronic disease

9. Pathogenesis Malabsorption /Steatorrhea • Celiac disease • Chronic Liver disease • Cystic Fibrosis • Chronic diarrhea

10. Pathogenesis Increase Energy Requirement • HIV • Congenital Heart disease • Hyperthyroidism

11. Etiology system based • GI • RS • CVS • Renal • ID • Genetic • Heme/Onc • Endocrine

12. GI Causes Feeding disorders Diarrhea Cleft palate Infectious Dentition Malabsorption oro-motor Vomiting Hepatic Biliary atresia GERD Chronic Hepatitis Stricture Cirrhosis

13. Pulmonary • CF • BPD • Tonsilar/ Adenoidal hypertrophy

14. Endocrine • Hypothyroid • Rickets • DM • GH deficiency • Adrenal insufficiency

15. Cardiac Causes • Congenital cardiac disease/CHF • POOR INTAKE • ? Increased metabolic demands • Possible fluid restrictions • Early interventions which may interfere with development of normal suck/swallow coordination

16. ID • HIV • TB • Parasites

17. Heme/Onc • Classic B-symptoms include • weight loss • anorexia

18. Genetic • Chromosomal abnormalities • Trisomy 13, 18, 21 • Deletion of chromosome 22 • Gonadal dysgenesis (45,X), etc • Evaluate for dysmorphisms

19. Renal • Renal Tubular Acidosis • Disorder of HCO3 and H+ reabsorption in renal tubules • Urine pH >5.5 in light of systemic acidosis

20. Diagnostic Classification of causes: inadequate Nutrition Intake • Not enough food offered • –Food insecurity • –Poor knowledge of child's needs • Poor transition to table food • Avoidance of high-calorie foods • –Formula dilution • –Excessive juice • –Breastfeeding difficulties • –Neglect • Child not taking enough food • –Oromotor dysfunction • –Developmental delay • –Behavioral feeding problem • Altered oromotor sensitivity • Pain and conditioned aversion • Emesis • –Gastroesophageal reflux • –Malrotation with intermittent volvulus • –Increased intracranial pressure

21. Malabsorption • Cystic fibrosis • Celiac disease • Food protein insensitivity or intolerance

22. Increase Metabolic demands • Insulin resistance (eg, intrauterine growth restriction) • Congenital infections (eg, human immunodeficiency virus, TORCH) • Syndromes (eg, Russell-Silver, Turner, Down) • Chronic disease (eg, cardiac, renal, endocrine)

23. Evaluation • Clinical History • Complete Physical Examination • Judicious Lab tests and other inv

24. History • Birth : IUGR,LBW,Prematurity, prenatal exposure alcohol, drugs • Chronic diseases • Recurrent infections • Frequent injuries • Review of systems

26. Feeding history • Kind, amount of formula • Preparation of formula • Excessive low calorie liquid/fruit • Stool pattern, vomiting with feeding • Special diet, vegetarian • Breast feeding techniques • CALORIE COUNT

27. Feeding history • Feeding environment • Feeding behaviour/interactions

28. Family history • Family members’ heights and weights • History of illness • Developmental delay • MID-PARENTAL HEIGHT • FAMILY GROWTH TREE

29. Psychosocial History • Financial & Employment status • Parental depression • Substance abuse • Family discordance /stress • Maladaptive parental styles

30. Physical Examination • Begin with measurements – if all parameters are <5th percentile, 70%chance of organic etiology • Need to follow pattern of growth (i.e.,isolated points are meaningless) • Dysmorphism • Palate intact • Hypotonia or spasticiy • Signs of neglect (diaper rashes, impetigo, • poor hygiene, protuberant abdomen)

31. Laboratory evaluation • Guided by clinical evaluation • No evidence extensive screening lab tests • Sever malnutrition: albumin, alkaline phosphatase, calcium, phosphorous • Diagnostic imaging studies based on clinical evaluation

32. Diagnosis FTT

33. Treatment • Nutrition Repletion • Treatment of underlying disease • Assessment oromotor function • Food intake 110-120% recommended intake

34. Treatment • Increased food intake; high calorie formula • Enrichment of food: supplementation with minerals and protein • Tube feeding/parentral feeding

35. Treatment • Addressing psychosocial stresses • Development and behavioral assessment • Child protection services

36. Hospitalization • Severe malnutrition • Significant dehydration • Serious intercurrent illness or significant medical problems • Psychosocial circumstances that put the child at risk for harm • Failure to respond to several months of outpatient management • Precise documentation of energy intake • Extreme parental impairment or anxiety • Extremely problematic parent-child interaction • Practicality of distance, transportation, or family psychosocial problems preclude outpatient management

37. Refeeding syndrome • Unknown pathology • Post nutrition rehabilitation in severe malnourishment • Changes in electrolytes( low phosphate, Mg,K) • Disruption fluid balance, edema • Impaired Heart function, hypoglycemia • Prevention by increased K, Phos,Mg during repletion • Montiore blood sugar,electrolytes,blood gases, wt,U/A

38. Sequelae • Early onset FTT, persistent reduction in Wt, Ht • Long term adverse effects cognition, learning, behavior