FAILURE TO THRIVE
Objectives
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1.To define failure to thrive (FTT)
— —2.To identify major classification of FTT
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— 3.To discuss diagnostic workup of FTT
4.To discuss treatment of FTT
Refer to growth below 3rd or 5th percentile or change in growth that
has crossed two major growth percentile(from above the 75th
percentile to below the 25th ) in a short time (less than 6 mo. )
— 1- organic 2- non organic, 3-25% mixed
— Prevalence •
— In developed countries= 5-10%
— In developing countries=much higher (poverty, malnutrition, HIV).
— Psychosocial more common in developed countries
Classifications •
I. Based upon Pathophysiology
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— 1.Inadequate caloric intake
2. Inadequate absorption
— 3.Increased metabolism
4.Defective utilization
A. Inadequate calorie intake •
— 1.Incorrect prep of formula
2. Unsuitable feeding habits
— 3.Behavior problems affecting eating (tantrums, pica, ..)
— 4.Poverty and food shortage
— 5.Neglect, Disturbed parent-child relationship
6.Mechanical feeding difficulties
— B. Inadequate absorption •
— 1.Celiac disease
2.Cystic fibrosis
— 3.Cow’s milk allergy
4.Biliary atresia or liver disease
— 5.Necrotizing enterocolitis or short gut
C. Increased metabolism
1.Hyperthyroidism
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— 2.Chronic infection- HIV, other immune diseases
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— 3.Hypoxemia-congenital heart defects and chronic lung disease
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— D. Defective utilization
1.Genetic abnormalities- trisomies 21, 18, 13
— 2.Congenital infections
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3.Metabolic disorders- storage diseases, amino acid disorders.
— II. According to causes.
1. Organic=
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1- GIS= GER, celiac disease, pyloric stenosis, malabsorption
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— syndromes, Chronic cholestasis, Chronic congenital diarrhea states.
— 2- Renal= Recurrent UTI, RTA, CRF
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— 3- Cardiopulmonary= CHF, severe asthma, cystic fibrosis.
— 4- Endocrine= DM. hyperthyroidism, Adrenal insufficiency.
— 5- Neurological = MR, CP
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— 6- Infection = HIV, TB, Perinatal infection (TORCHES),
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7- Metabolic = inborn error of metabolism
8- Congenital = Chromosomal disorders, Multiple congenital
anomaly syndromes
9- others= lead poising, Malignancy, Primary immunodeficiency
2. Non organic (psychosocial) =
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1-Inadequate diet because of poverty/food insufficiency, errors in
— food preparation .
— 2- Poor parenting skills (lack of knowledge of sufficient diet)
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3- Child/parent interaction problems (autonomy struggles, coercive
— feeding, maternal depression)
— 4- Food refusal
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— 5- Parental cognitive or mental health problems
— 6-Child abuse or neglect;
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7- emotional deprivation.
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— —III. Approach of FTT according to age
Age
DX consideration
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NEONATAL
Psychosocial( Failed breastfeeding , Improper
formula preparation ) , Congenital syndromes , Prenatal
— infections , Teratogenic exposure.
EARLY INFANCY Psychosocial ( Maternal depression
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Improper formula preparation , Child neglect ) Congenital heart
disease , Cystic fibrosis , Neurologic abnormalities , Recurrent
— infections
LATER INFANCY Celiac disease , Food intolerance , Child
neglect , Delayed introduction of age-appropriate foods
— Recurrent infections , Food allergy
AFTER INFANCY Acquired chronic diseases , Highly
distractible child , Inappropriate mealtime environment
Inappropriate diet, Recurrent infections.
—IV. Types of growth failure by using the growth chart
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Type 1= retardation of WT with near normal or slowly
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deceleration of HT, and OFC . Most common in under nutrition
Type 2= near proportional of WT ,and HT with normal OFC. e.g.
constitutional growth delay, genetic short stature, endocrinopathy,
— structural dwarfism.
Type 3= concomitant retardation of all parameters (HT, WT,
OFC) e.g. perinatal insult, chromosomal anomalies, and CNS
anomalies.
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Clinical manifestation
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The clinical presentation of FTT ranges from failure to meet
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expected age norms for height and weight to alopecia, loss of
subcutaneous fat, reduced muscle mass, dermatitis, recurrent
infections, and malnutrition (marasmus ,Kwashiorkor).
In developed countries, the most common presentation is poor
growth detected in an ambulatory setting;
In developing countries, recurrent infections, marasmus, and
kwashiorkor are more common presentation .
-- CLINICAL SIGNS OF MALNUTRITION
SITE
SIGNS
Face
Moon face (kwashiorkor), simian facies (marasmus)
Eye
Dry eyes, pale conjunctiva, Bitot spots (vitamin A), periorbital edema
Mouth
Angular stomatitis, cheilitis, glossitis, spongy bleeding gums (vitamin
C), parotid enlargement
Teeth
Enamel mottling, delayed eruption
Hair
Dull, sparse, brittle hair, hypopigmentation, flag sign (alternating
bands of light and normal color), alopecia
Skin
Loose and wrinkled (marasmus), shiny and edematous (kwashiorkor),
dry, follicular hyperkeratosis, patchy hyper- and hypopigmentation
(crazy paving or flaky paint dermatoses), erosions, poor wound
healing
Nails
Koilonychia, thin and soft nail plates, fissures or ridges
Musculature
Muscle wasting, particularly buttocks and thighs; Chvostek or
Trousseau signs (hypocalcemia)
Skeletal
Deformities, usually as a result of calcium, vitamin D, or vitamin C
deficiencies
Abdomen
Distended: hepatomegaly with fatty liver; ascites may be present
SITE
SIGNS
Cardiovascular
Bradycardia, hypotension, reduced cardiac output, small vessel
vasculopathy
Neurologic
Global developmental delay, loss of knee and ankle reflexes, impaired
memory
Hematologic
Pallor, petechiae, bleeding diathesis
Behavior
Lethargic, apathetic, irritable on handling
— Diagnosis
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The hx., physical examination and observation of the parent- child
interaction usually suggest the diagnosis. The latter observation,
especially with feeding, is often critical to the dx. Of psychosocial
FTT.
With young infants, its important to obtain detailed dietary Hx.,
including what the diet consist of, how often the infant is fed,
— &how periods.
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Children may have difficulty in swallowing if they have oral – —
motor dysfunction, or enlarge &recurrently infected tonsils
&adenoids. vomiting , diarrhea& malabsorption are general causes
of inadequate caloric absorption.
The laboratory evaluation of children with FTT is not always
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helpful and should be used judiciously.
A complete blood count, lead level, and urinanalysis represent a
— reasonable initial screen.
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Bone age is often helpful in distinguishing familial short stature
(bone age equivalent to chronological age) from endocrine or
nutritional abnormalities(bone age is less than chronological age).
Other test, such as for thyroid function , gastroesophageal reflux
— &malabsorption, & a.a., for cystic fibrosis (sweat test ).
Clinicians should be aware that celiac disease is more prevalent
than one thought, and should considered in infants and children
— with FTT and / or short stature.
In addition, because of possibility of allergic disease & availability
of quantitative RAST(radio-allergo-sorbent test) testing,
assessment of food allergy should be considered.
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Approach of FTT according to sign and symptoms
sign and symptoms
DX
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— 1.Spitting, vomiting, food refusal= GER, food allergy.
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— 2.Diarrhea, fat stool=
malabsorption, milk allergy
— 3.Recurrent wheezing=
Asthma, aspiration, food allergy
4.Recurrent infection =
diseases.
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HIV, congenital immunodeficiency
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Treatment
Regarding the cause , appropriate feeding atmosphere at home is
important
Organic= underlying cause should be treated, type of calorie
depend on the underlying cause e.g. CRF (protein).
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— psychosocial FTT=
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— 1- meal time 20-30 min
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— 2- solid food should be offered before the liquid
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— 3- environmental distraction should be minimized
— 4- child should eat with others
— 5- no force feed
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— 6- intake of water and juice should be minimized
— 7- high calorie should be required
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— The rule of 3's is quite helpful—3 meals, 3 snacks, and 3 choices
Weight gain in response to adequate caloric feedings usually
— establishes the diagnosis of psychosocial FTT.
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Indication of hospitalization
— 1- sever under nutrition
— 2- further diagnostic aids
— 3- luck of catch up growth
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4- evaluation of child-parent relation.
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The usual approach to the treatment of severe acute
malnutrition includes 3 phases .
The initial phase (1-7 days) is a stabilization phase. During this phase,
dehydration, if present, is corrected and antibiotic therapy is initiated to
control bacterial or parasitic infection.
Oral feedings are also started with specialized high-calorie formula,
proposed by the World Health Organization, that can be made with
simple ingredients. The initial phase of oral treatment is with the F75 diet
(75 kcal or 315 kJ/100 mL). The rehabilitation diet is with the F100 diet
(100 kcal or 420 kJ/100 mL). Feedings are initiated with higher frequency
and smaller volumes; over time, the frequency is reduced from 12 to 8 to
6 feedings per 24 hr. The initial caloric intake is estimated at 80-100
kcal/kg/day. In developed countries, 24-27 calorie/oz infant formulas may
be initiated with the same daily caloric goals. If diarrhea starts or fails to
resolve and lactose intolerance is suspected, a non–lactose-containing
formula should be substituted. If milk protein intolerance is suspected, a
soy protein hydrolysate formula may be used.
The second rehabilitation phase (wk 2-6) may include continued
antibiotic therapy with appropriate changes, if the initial combination was
not effective, and introduction of the F100 with a goal of at least 100
kcal/kg/day. This phase usually lasts an additional 4 wk. At any time, if
the infant is unable to take the feedings from a cup, syringe, or dropper,
administration by a nasogastric tube rather than by the parenteral route is
preferred.
Iron therapy usually is not started until this phase of treatment; iron can
interfere with the protein's host defense mechanisms. There also is
concern that free iron during the early phase of treatment might
exacerbate oxidant damage, precipitating infections (malaria), clinical
kwashiorkor, or marasmic kwashiorkor in a child with clinical marasmus.
Some recommend treatment with antioxidants.
By the end of the 2nd phase, any edema that was present has usually been
mobilized, infections are under control, the child is becoming more
interested in his or her surroundings, and his or her appetite is returning.
The child is then ready for the final follow-up phase, which consists of
feeding to cover catch-up growth as well as providing emotional and
sensory stimulation.
— Prognosis
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1- FTT in the 1st year is ominous sign
2- 1/3 of psychosocial FTT are delayed development
3- sever FTT have more than 8fold greater risk of mortality than
the normal
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4- moderate FTT, have more than 4-5fold greater risk of mortality
than the normal
5- mild FTT, have more than 2-3fold greater risk of mortality than
the normal.
catch-up-growth
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1.Gaining weight at a rate greater than 50th percentile for the age.
2.1.5 to 2 times the expected calorie intake for the age.
3.Energy –dense foods
Formula for calculating of catch-up-growth requirement
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Kcal or protein (g) for weight age X ideal body weight
Actual weight
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Re-feeding syndrome
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Refeeding syndrome can complicate the acute nutritional
rehabilitation of children who are undernourished from any cause
The hallmark of refeeding syndrome is the development of severe
hypophosphatemia after the cellular uptake of phosphate during the
1st week of starting to refeed. Serum phosphate levels of ≤0.5
mmol/L can produce weakness, rhabdomyolysis, neutrophil
dysfunction, cardiorespiratory failure, arrhythmias, seizures,
altered level of consciousness, or sudden death. Phosphate levels
should be monitored during refeeding, and if they are low,
phosphate should be administered during refeeding to treat severe
hypophosphatemia.
Calories can safely be started at 20% above the child recent
intake.Increased by 10-20% per day
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