FAILURE TO THRIVE.pptx

Approach to pediatric patients who are not gaining weight
FTT evaluation

1. FAILURE TO THRIVE DR. Habeeb Rehman KM

2. INTRODUCTION Descriptive term rather than a diagnosis Used for infants and children upto 3years of age whose physical growth is significantly less than their peers of same age and sex.

3. DEFINITIONS Weight for age below 3 rd centile for age on the growth chart or more than two standard deviations below the mean for children of same age and sex. Weight for height less than -2 Z score. Weight downcrossed two major centiles in growth chart in a short time

4. FTT - Classification MIXED

5. FTT - Classification NONORGANIC Prenatal Malnourished mother Lack of prenatal bonding Postnatal Poor feeding skills Dysfunctional family Difficult parent-child interactions Difficult Child Abuse/Neglect 15-Oct-20 5

6. Non organic causes Poverty Misperceptions or lack of knowledge about diet and feeding Lack of breast feeding Feeding diluted formula Dysfunctional parent-child relationship.

7. FTT - Classification ORGANIC FTT Prenatal Causes Prematurity and complications Toxic exposure Postnatal Inadequate intake Lack of appetite Inability to suck/swallow 15-Oct-20 7 postnatal Poor absorption and/or use of nutrients GI disorder (celiac, CF) Inborn errors of metabolism Increased metabolic demand Hyperthyroidism Chronic Disease

8. ETIOLOGY ORGANIC FTT Gastrointestinal- GER, malabsorption, inflammatory bowel disease, pyloric stenosis. Neurological- mental retardation, cerebral palsy. Renal- renal tubular acidosis, chronic renal failure. Cardiopulmonary- CHD, cystic fibrosis, asthma

9. ORGANIC FTT Endocrine- hypothyroidism, diabetes mellitus. Infections- chronic parasitic infections of GIT, tuberculosis, HIV Genetic- IEM, chromosomal anomalies. Miscellaneous – malignancy, lead poisoning

10. Etiology based on pathophysiology Inadequate nutrient intake Inadequate appetite or inability to eat large amounts Inadequate nutrient absorption or Increased losses Increased nutrient requirements or ineffective utilization

11. Etiology based on pathophysiology Inadequate nutrient intake Inappropriate feeding technique Disturbed caregiver/child relationship Economic deprivation Inappropriate nutrient intake ( eg , excess fruit juice consumption, factitious food allergy, inappropriate preparation of formula, inadequate quantity of food, inappropriate food for age, neglect, food fads ) Inappropriate parental knowledge of appropriate diet for infants and toddlers Insufficient lactation in mother Gastroesophageal reflux Psychosocial problems Mechanical problems (cleft palate, nasal obstruction, adenoidal hypertrophy, dental lesions) Sucking or swallowing dysfunction (CNS, neuromuscular, esophageal motility problems)

12. Etiology based on pathophysiology Inadequate appetite or inability to eat large amounts Psychosocial problems Cardiopulmonary disease Hypotonia , muscle weakness, or hypertonia Anorexia of chronic infection or immune deficienc y Cerebral palsy CNS pathology ( eg , tumor, hydrocephalus ) Genetic syndrome Anemia ( eg , iron deficiency) Chronic constipation Gastrointestinal disorder ( eg , pain from gastroesophageal reflux, intestinal tract obstruction) Craniofacial anomalies ( eg , cleft lip and palate, micrognathia )

13. Etiology based on pathophysiology Inadequate nutrient absorption or increased losses Malabsorption Biliary atresia , cirrhosis Vomiting or "spitting up" (related to infectious gastroenteritis, increased intracranial pressure, adrenal insufficiency, or drugs [ eg , purposeful administration of syrup of ipecac ]) Intestinal tract obstruction (pyloric stenosis , hernia, malrotation , intussusception ) Infectious diarrhea Necrotizing enterocolitis or short bowel syndrome

14. Etiology based on pathophysiology Increased nutrient requirements or ineffective utilization Hyperthyroidism Malignancy Chronic inflammatory bowel disease Chronic systemic disease (juvenile idiopathic arthritis ) Chronic or recurrent systemic infection (urinary tract infection, tuberculosis, toxoplasmosis ) Chronic metabolic problems (storage diseases, and inborn errors of metabolism, such as galactosemia , methylmalonic acidemia , diabetes mellitus, adrenal insufficiency) Chronic respiratory insufficiency ( bronchopulmonary dysplasia, cystic fibrosis) Congenital or acquired heart disease

15. Etiology by age of onset Prenatal Intrauterine growth restriction Prematurity prenatal infection congenital syndromes teratogenic exposures ( eg , anticonvulsants, alcohol).

16. Neonatal (<1 month) Poor quality of suck (whether breast- or bottle-fed) incorrect formula preparation breast-feeding problems inadequate number of feedings poor feeding interactions ( eg , infant gags or vomits during feedings, mother misreads signals of hunger or satiety) Neglect parental mental illness metabolic, chromosomal, or anatomic abnormalities.

17. 3 to 6 months Underfeeding (possibly associated with poverty) improper formula preparation milk protein intolerance oral motor dysfunction cystic fibrosis congenital heart disease gastroesophageal reflux.

18. 7 to 12 months Feeding problems (inadequate quantity/ frequency, delayed introduction of solids, intolerance of new foods) intestinal parasites.

19. >12 months highly distractible child distracting environment acquired illness new psychosocial stressor (divorce, job loss, new sibling, death in the family, etc) sensory-based feeding disorders in children with developmental disorders ( eg , autism) swallowing dysfunction.

20. Evaluation of a child with FTT HISTORY PHYSICAL EXAMINATION ANTHROPOMETRY INVESTIGATIONS

21. History Prenatal General obstetric history Recurrent miscarriages Use of drugs, smoking Natal, post-natal Prematurity Birth weight Neonatal asphyxia Congenital malformations or infections. Maternal bonding at birth

22. Evaluation of a child with FTT History Medical history Past medical / surgical illness Development Immunization Psychosocial history Age and occupation of parents Who feeds the child Life stressors Availability of social and economic support. History of violence or abuse of care-giver

23. Nutritional history Details of breast feeding. Formula feeds. Solid foods Vitamin and mineral supplements Food likes and dislikes, allergy

24. Physical examination Signs of PEM Signs of vitamin deficiency Dysmorphic features Serial growth parameters Development assessment Focussed examination for identifying chronic illnesses Signs of possible child abuse

25. LAB INVESTIGATIONS Not usually required if cause is psychosocial Donr to rule out Organic cause 1 st line:- CBC+ESR, URE+CULTURE, Stool r/e LFT,RFT,RBS, Electrolytes, ca, P, HIV & TB to be ruled out 2 nd line:- TFT, ABG, Celiac disese serology Urine for metabolic disease Echo, CXR, USG abdomen

26. Management Child’s diet and eating pattern Child’s development stimulation Improvement in care-giver skills Treatment of underlying disease if any Regular and effective follow up.

27. Diet and eating pattern Mothers should be counselled about feeding problems Avoid fruit juices Feeding interval should not be > 4hours. For older infants and young children meals should last for about 30 minutes.

28. solid foods should be offered before liquids. environment distractions should be minimised not to be force-fed. Catch up growth High calorie diet with 1.5 – 2 times the expected calorie. Gaining weight at a rate greater than 50 th percentile for the age.

29. Monitoring nutritional therapy 1st priority to achieve an ideal weight for age 2 nd goal is catch up length for age Effectiveness of therapy is monitored by gain in weight

30. Developmental stimulation Intensive environmental stimulation Foster homes

31. Other aspects Improvement in care-giver skills Treatment of underlying disease if any Regular and effective follow up.

32. Complications Malnutrition- infection cycle. Cognitive disability. Re-feeding syndrome.

33. APPROACH TO FTT

34. Thank you