Failure To Thrive

learn something about FTT, its etiologies,classofication,clinical features, growth curves, possible investigations and principles of managment

1. Seminar on: Failure to thrive GROUP – 5 BDU, CMHS C-1 01/01/ 2008 E.C 05/01/2008 E.C 1

2. Contents Definition Overview of Normal growth patterns Epidemiology Classification of FTT Risk factors Etiologies Approach a child with FTT Clinical manifestations Assessment of FTT Work UP Severe Acute Malnutrition 05/01/2008 E.C 2

3. Definition 05/01/2008 E.C 3

4. 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 sex Sign of unexplained Wt lose or poor Wt gain linear growth and head circumference also may be affected 05/01/2008 E.C 4

5. Cont’d... common terms to describe FTT; Failure to gain weight Failure to grow Growth deficiency Growth faltering Undernutrition 05/01/2008 E.C 5

6. 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. 05/01/2008 E.C 6

7. 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 05/01/2008 E.C 7

8. The most common definition is weight less than the 3 rd or 5 th 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) 05/01/2008 E.C 8

9. 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. 05/01/2008 E.C 9

10. 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 05/01/2008 E.C 10

11. 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 05/01/2008 E.C 11

12. 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 05/01/2008 E.C 12

13. 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 05/01/2008 E.C 13

14. Head Growth 05/01/2008 E.C 14 Head circumference: A verage 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

15. 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 05/01/2008 E.C 15

16. Exception to the definition Children 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 05/01/2008 E.C 16

17. Epidemiology 05/01/2008 E.C 17

18. EPIDEMIOLOGY True incidence of FTT is not known In developed nations 5–10% of young children 3–5% of children admitted into teaching hospitals Prevalence higher in developing countries , why? Poverty malnutrition HIV infection 05/01/2008 E.C 18

19. Cont’d... Under-feeding is the single commonest cause of FTT 95% of cases of FTT  i nadequate 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 05/01/2008 E.C 19

20. Risk Factors 05/01/2008 E.C 20

21. 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 05/01/2008 E.C 21

22. Psychosocial risk factors for FTT include: Poverty Certain 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 05/01/2008 E.C 22

23. Classification 05/01/2008 E.C 23

24. 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 05/01/2008 E.C 24

25. 3 . Mixed FTT Organic and non organic causes coexist. Those with organic disorders may also suffer from environmental deprivation Likewise, those with severe undernutrition From non-organic FTT can develop organic medical problems 05/01/2008 E.C 25

26. 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 , 05/01/2008 E.C 26

27. Etiologies of FTT 05/01/2008 E.C 27

28. Etiologies Etiologies of FTT by pathophysiology 1. Inadequate caloric intake Inappropriate 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 05/01/2008 E.C 28

29. Disturbed caregiver/child relationship Economic deprivation Insufficient lactation in mother Mechanical problems (cleft palate, nasal obstruction, adenoidal hypertrophy, dental lesions) Sucking or swallowing dysfunction (CNS, neuromuscular) 05/01/2008 E.C 29

30. 2. Inadequate Absorption or Increased Losses Malabsorption lactose intolerance cystic fibrosis cardiac disease malrotation inflammatory bowel disease(IBD) milk allergy parasites celiac disease 05/01/2008 E.C 30

31. Biliary atresia Cirrhosis Vomiting Infectious gastroenteritis Increased intracranial pressure Intestinal tract obstruction (pyloric stenosis, hernia, malrotation, intussusception) Infectious diarrhoea Necrotizing enterocolitis or short bowel syndrome 05/01/2008 E.C 31

32. 3. Increased Caloric Requirement Hyperthyroidism Malignancy Chronic inflammatory bowel disease Chronic systemic disease (juvenile idiopathic arthritis) systemic infection Urinary tract infection Tuberculosis Toxoplasmosis 05/01/2008 E.C 32

33. Chronic metabolic problems Hypercalcemia Storage diseases Inborn errors of metabolism galactosemia diabetes mellitus adrenal insufficiency Chronic respiratory insufficiency bronchopulmonary dysplasia cystic fibrosis Congenital or acquired heart disease 05/01/2008 E.C 33

34. 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 05/01/2008 E.C 34 Organic Causes Of FTT

35. 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 05/01/2008 E.C 35

36. … NEUROLOGIC Cerebral palsy Hypothalamic and other CNS tumors Neuromuscular disorders Neurodegenerative disorders RENAL Urinary tract infection Renal tubular acidosis Renal failure 05/01/2008 E.C 36

37. … ENDOCRINE Diabetes mellitus Diabetes insipidus Hypothyroidism/hyperthyroidism Growth hormone deficiency Adrenal insufficiency 05/01/2008 E.C 37

38. 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) 05/01/2008 E.C 38

39. MISCELLANEOUS Collagen-vascular disease Malignancy Primary immunodeficiency Transplantation INFECTIONS Perinatal infection (TORCH) Occult/chronic infections Parasitic infestation Tuberculosis HIV 05/01/2008 E.C 39

40. Non-organic FTT (Psychosocial/Behavioral ) Commonest Cause Inadequate diet because of poverty/food insufficiency Errors in food preparation Child/parent interaction problem Poor parenting skill (lack of knowledge of sufficient diet/feeding techniques) Food refusal Parental mental health/cognitive problems 05/01/2008 E.C 40

41. …. Child abuse/neglect Family dysfunction: marital stress, mental illness, substance abuse, … Infant co-morbidities Unintentional Emotional deprivation 05/01/2008 E.C 41

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44. Approach to A child with Failure To Thrive

45. 1. History Taking Prenatal History Smocking Alcohol consuming Use of medication Any illness during pregnancy

46. 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

47. History Feeding history Details breast and 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

48. History 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

49. History

50. History

51. History Family History s tature and growth patterns Medical problems Genetic diseases Developmental delays

52. 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

53. 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

54. History Growth and eating pattern of other siblings Young parental age Affluent circumstances or parents engaged in career development Child rearing beliefs

55. History Poverty, 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

56. 2. Physical Examination The four main goals of physical examination include Identification of dysmorphic features suggestive of a genetic disorder that affects growth Detection of an underlying disease that may impair growth Assessment for signs of possible child abuse Assessment of the severity and possible effects of malnutrition

57. Physical examination General appearance Cachexia, temporal wasting, sparse hair or alopecia  malnutrition Dysmorphic features Small palpebral fissures Midface hypoplasia Flat philtrum Thin vermilion border of fetal alchohol syndrome)

58. Physical examination Vital signs Temperature  hypothermia PR  tachycardia RR  tachypenic BP  hypotension Anthropometry  derangements

59. Physical examination 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

60. Physical examination Chest Wheezing Crackles Prolonged expiratory phase Hyperexpansion Abdomen Abdominal distension hyperactive bowel sounds Hepatosplenomegaly

61. 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

62. Physical examination Skin and Mucous Membranes Pallor Clubbing Scaling skin Spoon-shaped nails Iron deficiency Cheilosis Vitamin deficiency Chronic diaper rash

63. Physical examination Neurologic Abnormal deep tendon reflexes Hypotonia Weakness Spasticity Neuropathy

64. 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 05/01/2008 E.C 64

65. Clinical Features

66. Most common clinical presentation is poor growth Accompanied by physical signs; Alopecia Reduced subcutaneous fat or muscles Dermatitis Syndromes of marasmus or kwashiorkor

67. Failure to meet expected age norms for ht and wt Recurrent infections Depending on the severity infants with FTT may exhibit Thin extremities Narrow face Prominent ribs and wasted buttocks

68. Cont’d… Neglect of hygiene Diaper rash Unwashed skin Uncut and dirty finger nails or unwashed clothing Delays in social and speech development Expressionless face and hypotonic

69. 05/01/2008 E.C 69 Assessment of FTT

70. Anthropometric criteria: 1 . A child younger than 2 years of age whose weight is less than the 3 rd or 5 th 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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73. 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 . 05/01/2008 E.C 73

74. Recommended growth charts WHO 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 05/01/2008 E.C 74

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76. Work Up 05/01/2008 E.C 76

77. 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 05/01/2008 E.C 77

78. Simple routine tests includes: Random Blood Sugar(RBS) complete blood count(CBC) Urinalysis(U/A) electrolyte levels stool exam PIHCT TB 05/01/2008 E.C 78

79. Severe Acute Malnutrition 05/01/2008 E.C 79 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

80. 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) 05/01/2008 E.C 80

81. Investigation: RBS -------Hypoglcemia CBC --------Hct, Hb U/A -------- UTI Serum electrolytes- --↑Na+, ↓K+ stool exam- --parasites chest X-ray- Blood culture sepsis HIV test 05/01/2008 E.C 81 Pneumonia ,TB

82. THANK YOU 05/01/2008 E.C 82