Failure to Thrive

1. Failure to Thrive Premi Suresh, MD, FAAP

2. Learning Objectives

3. Background • Failure to Thrive (FTT) is a common problem in pediatric populations • Accounts for 1-5% of referrals to children’s hospitals/tertiary care centers • May be under diagnosed • 20-50% may not be picked up by physician

4. Background • In low-income countries, poverty is the most common cause of Failure to Thrive; however, medical providers, social services and law enforcement must learn about the entire family to see if this child – for any reason – was not given food that was given to others in the family.

5. GROWTH CHARTS

6. Growth Charts • U.S. Centers for Disease Control (CDC) • Growth reference • How children grow in the U.S. • World Health Organization (WHO) • Growth standard • How children should grow in ideal conditions • Recommended for use in children under 2

7. CDC or WHO? • WHO growth chart may be better for children under 2 years old • WHO more appropriate for exclusively breastfed infant • WHO may take into account cultural differences • Still no consensus among providers

8. CDC chart

9. WHO Chart

10. FAILURE TO THRIVE

11. Failure to Thrive • Not a diagnosis - a description • Inadequate nutrition to sustain normal growth and development • Significantly prolonged cessation of appropriate weight gain compared with recognized norms for age/gender after having achieved stable pattern

12. Criteria • Weight curve crossing 2 major percentile lines on growth chart after achieving stable pattern • Weight for age or weight for height more than 2 standard deviations below mean for gender/age

15. Weight for Height

16. Thomas

17. Midparental height Father’s ht (in) + Mother’s ht (in)+5 2 Boys: Girls: Father’s ht (in) + Mother’s ht (in) -5 2

19. Organic vs. Non-Organic • Not a helpful distinction • Both overlap • Too simplistic • Malnutrition causes growth failure

20. Causes of FTT • Inadequate calories • Inability to utilize calories • Increased caloric needs More than one of these causes can overlap!!

21. Normal Growth Food (calories) Waste Metabolism Growth

22. Inadequate Calories • Lack of knowledge • Behavior • Psychosocial • Anatomic

23. Inadequate Calories Lack of knowledge • Diet (low calorie, excess juice, fads) • Formula mixing Behavior issues • Grazing • Behavior problems • Oral aversion • Food phobia

24. Feeding Infants • Breast milk or formula in first year of life • No water needed in first 4-6 months • Offer water in sippy cup • Solids introduced at 4-6 months • Juice not necessary! • Should not exceed 4-6 ounces/day • Transition to WHOLE milk at 1 yr of age

25. Growth in infancy

26. Caloric intake • Breastmilk and Standard Infant formula have 20 calories per oz • Formula should be mixed 1 scoop to 2 oz water • There are special formulas with higher calories per oz

27. Toddlers • Growth less rapid • Can become picky • Food “jags” • Bottle should be discontinued • Self feeding encouraged • Avoid battles over food

28. Stop Grazing • Offer 3 meals and 3 snacks per day • Separate meals and snacks by 2-2.5 hours • Only water between meals and snacks • Meals and snacks should be offered at a table or highchair and should last 20-25 minutes • Solid foods should be offered before liquids

29. Inadequate Calories Psychosocial • Poverty/financial • Formula mixing • Abuse/neglect/IPV • Parental mental health issues • Parental eating disorders

30. Inadequate Calories Anatomic • Congenital anomalies • Oromotor dysfunction • Dental caries • Gastroesophageal reflux • Obstruction (i.e. pyloric stenosis)

31. Inability to Utilize Calories Malabsorption Milk protein allergy Cystic fibrosis Pancreatic insufficiency Biliary atresia Short gut or necrotizing enterocolitis Inflammatory bowel disease Chronic diarrhea Disaccharidase deficiency Improper utilization Inborn errors of metabolism Storage disorders Growth hormone deficiency

32. Increased Caloric Needs • Prematurity • Recurrent infection • Cardiac disorders • Congenital heart disease, heart failure • Pulmonary disorders • Chronic lung disease, poorly controlled asthma • Cancer • Kidney problems • Renal tubular acidosis, chronic renal failure • Chronic liver disease • Obstructive sleep apnea • Chronic infection (HIV, Tuberculosis)

33. Case Scenario • Pt is a 2 yr 5 mo male brought to the Hospital after being found unresponsive at home. Doctors found the patient’s abdomen was abnormally large, his legs were extremely swollen and face and arms appeared malnourished and gaunt. Doctors report that patient has been found to have a large abdominal tumor. Per mother’s report patient has been “unwell” for several months.

35. Findings • Tumor: Metastatic Wilms (weighed 5 kg) • Albumin <1 • Prealbumin 9 (nl 19-38) • 3>5.4<53 • Head CT- brain atrophy • Bony demineralization

37. Is this patient failing to thrive?

38. Causes of FTT • Inadequate calories • Inability to utilize calories • Increased caloric needs More than one of these causes can overlap!!

39. CHILD ABUSE CAUSES OF FTT

40. Child abuse causing FTT • Neglect • Pediatric Condition Falsification • Other- effects of physical abuse, sexual abuse

41. Case Scenario Patient is a 2 month old male. Mother took him to the primary doctor for immunizations. Doctor became concerned because the baby was very small and considered to be failure to thrive. Baby’s birth weight was 6 lbs, 6oz ( 3.3 Kg). At 1 month of age baby weighed 7 lbs, 6 oz. At today’s 2 month visit, baby weighed 7 lbs 5 oz. Mother told doctors that she gives the baby 32 oz of formula per day which the doctors said was an appropriate amount. Nurses report that mother is not engaged in the child’s care and sleeps most of the time. Nursing staff had to wake mother to participate in diaper changes and feedings.

42. Child Abuse Causing FTT • Neglect • Food withholding • Caregiver mental health issues • Caregiver substance abuse • Poor attachment • Domestic violence • Lack of follow through/medical neglect

43. Case Scenario

44. Case Scenario

45. Case Scenario

46. Case Scenario Patient is a 12 month old female with failure to thrive. Hospital physicians are concerned because child appears to be normal, eat well and gain weight while in the hospital. However, child’s primary physician is worried that the child has an underlying medical condition. She frequently has diarrhea and has days where she vomits with every meal. The child has had numerous medical lab tests and imaging studies that have not determined what is causing her vomiting and diarrhea. Mother brings the child to all appointments and seems very appropriate and engaged in child’s care.

47. Child Abuse Causing FTT • Fabricated or Induced Illness (Medical Child Abuse or Pediatric Condition Falsification • Induced FTT • Giving the child laxatives, ipecac, etc • Fabricated symptoms • Reporting symptoms that child not experiencing • Leads to further workup, tests

48. Child Abuse Causing FTT Pediatric condition falsification (PCF) • Caregivers typically present well • May be extremely attentive • “Model” caregivers • Will be opposite of caregivers who are neglecting the child

49. Child Abuse Causing FTT • Physical/Sexual abuse • Could cause behavioral symptoms that lead to failure to thrive • Food refusal • Vomiting • Can co-exist with neglect

50. Evaluation & Management • History • Physical exam • Laboratory testing • Treatment