Failure to Thrive GIT Lec. 5 (FTT) By Dr. Athal Humo

Objective of Lec.5 FTT To define FTT. To know its causes. To distinguish its manifestation. Approach to investigate a child with FTT. How you can manage a case.  

Failure to Thrive (FTT) FTT is a term given to malnourished infants and young children who fail to meet expected standards of growth. FTT is a common problem in pediatrics, affecting 5% to 10% of young children and approximately 3% to 5% of children admitted to hospitals. FTT is more common in children living in poverty and foster care and affects 15% of these group.

Definition of FTT weight that falls or remains below the 5th percentile for age. weight that decreases crossing two major percentile lines on the growth chart over time, (i.e., from above the 75th percentile to below the 25th) weight that is less than 80% of the median weight for the height of the child

In children with FTT, malnutrition initially results in: Wasting (deficiency in weight gain). then Stunting (deficiency in linear growth) generally occurs after months of malnutrition. Head circumference generally is spared except with chronic, severe malnutrition.

The weight for age per cent of the standard value decreases early in the course of FTT, followed by a decrement of height for age. So: Weight for height below the 5th percentile remains the single best growth chart indicator of acute undernutrition Children with chronic malnutrition often have a normal weight for height because both their weight and height are reduced. NOTE: Allowances must be made for prematurity; OFC corrections are needed until 18 months of age. weight corrections are needed until 24 months of age. height corrections are needed until 40 months of age.

Causes of FTT: Non organic ( psychosocial FTT). Organic FTT is marked by an underlying medical condition

Non organic or psychosocial FTT: It is far more common than organic FTT. Psychosocial FTT is most often due to poverty or poor child-parent interaction. Causes of Non organic (psychosocial FTT): Lack of food ( poverty) Lack of knowledge, (poor feeding techniques ,improper formula preparation, improper mealtime environment) Parental depression ,emotional deprivation, Child abuse or neglect .

Organic Causes of Failure to Thrive: Any chronic disease may lead to FTT Gastrointestinal: GER, celiac disease, pyloric stenosis, cleft lip/ palate, lactose intolerance, Hirschsprung's disease, milk protein intolerance, hepatitis, cirrhosis, pancreatic insufficiency, biliary disease, inflammatory bowel disease, malabsorption Renal: UTI, RTA, DI, RF Cardiopulmonary: Cardiac diseases leading to CHF, asthma, BPD, CF, anatomic abnormalities of the upper airway, Endocrine: Hyperthyroidism, DM, adrenal insufficiency or excess, parathyroid disorders, pituitary disorders, Neurologic: MR, CP, degenerative disorders, CNS tumors Infectious: Parasitic or bacterial infections of the gastrointestinal tract, TB, HIV disease Metabolic: IEM Genetics, Congenital: Chromosomal abnormalities, congenital syndromes (fetal alcohol syndrome), perinatal infections Miscellaneous :Lead poisoning, malignancy, collagen vascular disease, recurrently infected adenoids and tonsils

DIAGNOSIS AND CLINICAL MANIFESTATIONS History prenatal and postnatal factors : That influence growth, including the history of prenatal care, maternal illnesses during pregnancy, to Identify fetal growth problems (IUGR), birth size (weight, length, and head circumference). Identify prematurity Indicators of medical diseases (review of systems): such as vomiting, diarrhea, fever, respiratory symptoms, etc Careful dietary history is essential: The adequacy of the maternal milk supply or the precise preparation of formula should be evaluated. For older infants and young children, a detailed diet history is helpful, it is essential to evaluate intake of solid foods and liquids. Because of parental dietary beliefs, some children have inappropriately restricted diets. Other children with FTT drink excessive amounts of fruit juice, leading to malabsorption or anorexia for more nutrient-dense foods.. Social environment: poverty, unemployment, illiteracy, conflict , disruptive parent-child interactions

Growth chart: weight, height, OFC Systemic examination: Physical examination : Growth chart: weight, height, OFC Systemic examination: Physical findings related to malnutrition, such as dermatitis, pallor, or edema Additionally, severely malnourished children are at risk for a variety of infections.

Depending on severity, the infant with FTT may exhibit thin extremities, a narrow face, prominent ribs, and wasted buttocks. Neglect of hygiene may be evidenced by diaper rash, unwashed skin, untreated impetigo, uncut and dirty fingernails, or unwashed clothing. A flattened occiput with hair loss may indicate that the child has been lying on his or her back. This flattening may be due to being unattended for prolonged periods. Delays in social and speech development are common. Other findings may include an avoidance of eye contact, an expressionless face, hypotonia, and the absence of a cuddling response.

Laboratory evaluation: There is no need for extensive laboratory search for medical diseases Simple screening tests are recommended to screen for the common illnesses that may cause growth failure and to search for medical problems that result from malnutrition. Recommended laboratory tests include: CBP : type of anemia, WBC abnormalities (leucocytosis, lymphopenia) Urinalysis, urine culture: UTI Serum electrolytes & RFT Serum protein: Degree of protein deficiency Blood sugar: hpoglycemia Stool sample for culture and ova and parasites may be indicated for children with diarrhea, abdominal pain, or malodorous stools. PPD: screen for TB

TREATMENT Most children with FTT can be treated in the outpatient setting. Hospitalization is required for Children with severe malnutrition. Children with underlying diagnoses that require hospitalization for evaluation or treatment. Children whose safety is in danger because of maltreatment( social issues of the family).

Nutritional management: It is the cornerstone of treatment of FTT, regardless of the etiology. In general, the simplest and least costly approach to dietary change is warranted.

Amount: SLOW GRADUAL INCREMENT Calories can be safely started at 20% above the child recent intake If no estimate of the caloric intake is available,50-75% of the normal energy requirement is safe. Caloric intake can be increased 10-20% per day. with monitoring for electrolyte imbalances, poor cardiac function, edema, or feeding intolerance. If any of these occurs, further caloric increases are not made until the child's status stabilizes. The final target is to provide 100 to 120 kcal/kg based on ideal weight.

Type: according to age of the child & type of feeding : Breast fed infant: continue breast feeding and may add cow milk or special cows’ milk based formula (F75 or F100). Bottle fed : Increased amount of cow milk ,or change to other types if indicated like: special cows’ milk based formula(F75 or F100) calorically dense formula (for anorectic and picky eater) concentration of formula can be changed from 20 cal/oz to 24 or 27 cal/oz soy based (isomil) for lactose-intolerant child hydrolyzed protein type (pregestemil) for cow milk protein intolerant home made (oil,butter,peanut butter, others) Toddlers: Dietary changes should include increasing the caloric density of favorite foods by adding butter, oil, peanut butter, or other high-calorie foods. High-calorie oral supplements that provide 30 cal/oz are often well tolerated by toddlers.

Vitamin and mineral supplementation: It is needed, especially during catch-up growth. Vitamin and mineral intake in excess of the daily recommended intake is provided to account for the increased requirements; this is frequently accomplished by giving an age-appropriate daily multiple vitamin.

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