Failure To Thrive

1. Failure To Thrive Dr. SamathaMadhavarapu PGY-2

2. Objectives • Normal Growth Patterns • Definitions • Classification of FTT • Etiology • History • Physical Exam • Lab work • Treatment

3. Why do you need to know? • FTT is a common sign and remains diagnostic and therapeutic challenge. • 10% of children in primary care settings show signs of failure to thrive • FTT accounts for 1-5% of pediatric hospital admissions

4. Historical Overview • The Diseases of Infancy and Childhood by L. Emmett Holt in 1897- reference to an infant who "ceased to thrive“. • “Fail to thrive"first in 1933 in 10th edition. • 1967- psychosocial aspectsof failure to thrive became synonymous with maternal deprivationsyndrome /parental" deprivationsyndrome DSM-III as "reactive attachmentdisorder

5. Normal Growth Patterns • Term infants: Lose 5-10% of birth wt, regain by 10-14 days. • Infants wt gain pattern: 1 kg/mo for the first 3 months 0.5 kg/mo from age 3-6 months 0.33 kg/mo from age 6-9 months 0.25 kg/mo from age 9-12 months Double the birth weight by 4-5 mo Triple the birth weight by 1 yr of age

6. Growth Pattern Contd • Term infants : 1st 3 months gain 25-30 g/day 3- 6 months gain 15-20 g/day 6months to 1 year of age, 12g/day 0.25 kg/mo until toddler 2 kg/y through early school age. • Growth of Length : 25 cm in first 1 yr 12.5 cm in 2nd yr 5-6 cm between 4yrs and puberty onset upto 12 cm at onset of puberty

7. Growth Pattern Contd • Head Circumference: Average at birth 35cm 47 cm by age 1 year, rate then slows Average of 55 cm by age 6 years • Caloric Requirements: 100-110 kcal/kg/d for the first half year 100 kcal/kg/d for the second half of the first year Beyond 10 kg, 50 kcal/kg/d is required until 20 kg Beyond 20 kg, 20 kcal/kg/d are necessary. Premature infant usually require 120-140 kcal/kg/dayprior to 40 wks gestation.

8. Definition of FTT • Sign of unexplained weight loss or poor weight gain in a child or infant . • 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.

9. Definition • Weight for Length: weight-for-length < 80% of ideal weight - Actual weight <70% of predicted weight-for-lengthrequires urgent attention • Weight for age decreases early in the course of FTT, followed by height.

10. Exceptions to the definition • child with genetically short stature, SGA infants, Preterm infants, and “over-weight” infants , whose height gain exceeds weight gain. • Preterm infants : Plot using corrected age until 2 yrs of age if birth wt >1000gm until 3 yrs of age if birth wt < 1000gm Catch up growth for Primi: 18 mns for Head circumference 24mns for weight 40 mns for height

11. Classification of FTT • Historically : Organic and Nonorganic • Organic FTT: underling major disease process • Non organic FTT / Psychosocial FTT: environmental or social factors , no medical problem • not mutually exclusive • false dichotomy. • Mixed may be present when the effects of organic disease are combined with concurrent psychosocial problems. • FTT is a spectrum , with purely organic and purely environmental being the extremes.

12. National Center for Health Statistics (NCHS) developed growth charts in 1977. • 2000 CDC growth charts represent the revised version of the 1977 • Data from National Health and Nutrition Examination Survey (NHANES) is used to revise the charts.

13. Growth Charts • Infants, birth to 36 months Weight-for-age Length-for-age Weight-for-length Head circumference-for-age • Children and adolescents, 2 to 20 years Weight-for-age Stature-for-age Body mass index-for-age

14. FTT Severity Grading

15. Special growth charts • Trisomy 21, • Prader-Willi • Williams syndrome • Turner • Meningomyelocele • Marfan • Achondroplasia.

16. Epidemiology • Prevalence depends on population sampled. • 5-10% of primis and children living in poverty in developed nations. • Developing nations with high rates of malnutrition and or HIV infection. • Nonorganic FTT is far more common in USA and other industrialized countries.

18. Etiology : ORGANIC Respiratory • Obstructive: Tonsillarhypertrophy, OSA CF Asthma BPD Chronic resp failure • Infectious Disease TORCH Chronic infections Parasitic infections TB/HIV • Genetic/Metabolic/ Chromosomal disorders Inborn errors of metabolism Congenital syndromes Sickle cell disease Fetal alcohol syndrome • CNS CP Hypothalamic /CNS tumors Neuromuscular disorders Lead toxicity

19. Etiology • Cardiac CHF Cyanotic heart disease Vascular rings • Renal UTI/ Chronic pyelonephritis RTA Renal Failure • Endocrine Hypothyroidism/Hyperthyro Diabetes Rickets Growth hormone deficiency Adrenal insufficiency

20. Gastrointestinal Pyloric stenosis GERD Malabsorption Celiac disease Milk intolerance: lactose, protein Inflammatory Bowel Disease Short bowel syndrome Food allergy Hirschsprung Chronic cholestasis Pancreatic insufficiency Chronic infant/ toddler diarrhea

21. Malnutrition and FTT • Inadequate calorie intake • Inadequate calorie absorption • Excessive calorie expenditure

22. Non-organic causes(Psychosocial/Behavioral) • Inadequate diet-poverty • Poor parenting skills (lack of knowledge of sufficient diet/ feeding technique) • Child/ Parent interaction problems • Food refusal • Parental mental health/ cognitive problems • Child abuse/ neglect

23. Etiology Emotional deprivation Family dysfunction: marital stress, mental illness, substance abuse, spousal abuse, Infant comorbidities Unintentional

24. HISTORY • GOLDEN RULE :Comprehensive History and Physical Exam • Prenatal events : Medical complications of pregnancy, IUGR Alcohol, smoking Mother’s emotional reaction to the pregnancy. • Birth history and nursery course

25. Detailed feeding history : • Details of breast/ formula feeding • Typical 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 • A 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

26. History • Medical history and review of systems may reveal existing or undiagnosed conditions • Spitting/vomitting/food refusal • Diarrhea/fatty stools • Snoring/mouth breathing/enlarged tonsils • Recurrent wheezing/pneumonias • Recurrent infections • Travel to/ from developing countries

27. Psychosocial history • Family composition • Any major events in the child’s life • Family stressors Chronic Illness, Martial stress Single parenthood Depression Domestic violence Substance abuse, Employment / financial obligations. • Growth and eating pattern of other siblings • Young parental age • Affluent circumstances or parentsengaged in career development • Child rearing beliefs

28. History Family history stature and growth patterns Medical problems Genetic diseases Developmental delays Developmental History of the child

29. PHYSICAL EXAM • Measure head circumference, weight, and length • Analyze previous growth curves • loss of subcutaneous fat &muscle mass • wasted buttocks

30. Untreated impetigo • Uncut/dirty fingernails • Delays in social and speech development • Lack of eye contact • Expressionless face • Hypotonia • Edema /ascites • Thin extremities • Hepatomegaly • Heart murmur • Skin changes • Signs of vitamin deficiency • Hair changes

31. Lab work • Mostly inconclusive • Guided by history and physical exam • CBC (Anemia) • BMP with Mg (RTA/ metabolic disorders) • U/A (Renal / Metabolic ) • Lead level • TFT • ESR/CRP (sign of inflammation/infection

32. Lab work • Stool - fat, pH, reducing substances, occult blood, ova and parasites, • sweat chloride, • TB and HIV • Celiac Panel • Bone age (familial short stature vs endocrine/nutritional ) • Skeletal survey in < 2yr old with ? Physical abuse • Urine –organic and amino acids • Food allergy assessment

33. Management • Organic FTT : Determine and treat the underlying cause • Non-organic FTT : • Hospitalize Sustained catch up growth (>30g/day ) Educate parents • Multidisciplinary approach (Nutritionist, social worker, pediatrician) • ACS.

34. Management Monitor I/O’s, Daily weight Monitor feeding technique Age appropriate 150 Kcal/Kg (ideal wt) per 24hr Fortify the formula High calorie foods (peanut butter, whole milk, dried foods)

35. Management • Adding iron and Vitamin D , zinc • Family centered approach • Reinforce positive behavior • Solid foods should be offered before liquids • Minimize environmental distractions • High calorie supplementation –Duocal,Polycose, Carnation Instant Breakfast, Formulas > 20cal/oz (Pediasure, Ensure, Resource)

36. Observation during non feeding times : level of nurturing and responsiveness of the parent • degree to which the child seeks the parent in times of need, amount of time parent cuddles/holds baby

37. Hospitalization • Severe malnutrition • hypothermia, • Bradycardia /hypotension • Further diagnostic/ lab workup • If abuse or neglect is suspected • Lack of catch-up growth following outpatient management. • Evaluating parent-child feeding interaction .

38. Prognosis • FTT in 1st yr- ominous • 1/3 with psychosocial FTT –developmental delay, social , emotional problems • Organic FTT- variable, depends on cause and severity of FTT • Need ongoing monitoring of cognitive and emotional development

39. Summary FTT is a common sign which poses diagnostic and therapeutic challenge to pediatricians. Monitor growth patterns of children Good history and physical exam are the key for diagnosis Address both organic and nonorganic causes for any child with FTT Needs Multidisciplinary approach for management

40. References • Behrman, R., et al. Nelson’s Texbook of Pediatrics. 14th edition • Schecter, M, MD, Adam, H, “Weight Loss and Failure to Thrive.” Peds in Review. July 2000; 21(7) 238-239 • Schwartz, I., MD. “Failure to Thrive: An old Nemesis in the New Milennium.” Pediatrics in Review. August 2000; 21(8) 257-264 • Zenel, J, MD. “Failure to Thrive: A General Pediatrician’s Perspective.” Pediatrics in Review. November 1997; 18(11) 371-378. • Block, Nancy,Committee on Child Abuse and Neglect and the Committee on Nutrition. “ Failure To Thrive as a Manifestation of Child neglect”PEDIATRICS Vol. 116 No. 5 November 2005, pp. 1234-1237 • Ficicioglu.C, Christina.K, MD. “Failure to Thrive: When to Suspect Inborn Errors of Metabolism”. PEDIATRICS Vol. 124 No. 3 September 2009, pp. 972-979

41. Question • You are working in the emergency department when a mother brings in her 8-month-old son. She is concerned because he has had diarrhea for 2 months that has worsened over the last day. She explains that the stool is greasy, but there is no blood. He has had two episodes of sinusitis but no hospitalizations. They are new to town and he has not seen a physician since his 2-month health supervision visit. On physical examination, the boy appears pale, cachectic, and mildly dehydrated but alert. He has nasal congestion, his lungs are clear, and findings on his abdominal examination are normal. His weight is below the 5th percentile, length is at the 10th percentile, and head circumference is at the 25th percentile. He has a foul-smelling, greasy stool in his diaper.Of the following, the test MOST likely to reveal the diagnosis is

42. A. enzyme-linked immunosorbent assay for Giardia • B. serology for antigliadin antibodies • C. stool evaluation for alpha-1-antitrypsin • D. stool evaluation for ova, cysts, and parasites • E. sweat test

43. Thank You !!