2 year old Failure to Thrive General GI Inpatient | Children’s National Medical Center Alyssa Ardolino, B.S. Dietetic Intern University of Maryland College Park May 2017

Objectives Overview of condition Meet ZS Nutrition Assessment Plan of Care Summary

Overview of Condition

What is Failure to Thrive? Failure to thrive is a situation where an infant, toddler, or child is undernourished and doesn’t receive or cannot process enough calories. Example: a toddler who is consistently below the standard weight range (<5th %ile) for his or her developmental stage. Organic: underlying medical cause Inorganic: usually occurs in a child who is younger than 2 years old and has no known medical condition that causes poor growth. According to the NIH, the best approach is with a multi-disciplinary team including an RD, a physical therapist, a gastroenterologist, and a psychologist. Early detection and intervention improve outcomes.

Meet ZS

Background Born 1/31/15 (now 28 months old) Full term (38 weeks) Birth weight 5 lbs 7.2 oz Physical Appearance: Malnourished, thin Activity Level: moderate PMH: Significant for poor weight gain, chronic short stature, eczema, and speech delay Exclusively breastfed at birth until Enfamil was added at 3-4 mo. He started soft table foods at 9 mo. Patient has tried various diets and Pediasure, which he dislikes. Per patient’s mother, he is likely to mimic those around him while eating and stops when they stop. Patient often fills up on vegetables or starches and does not eat much meat or protein. No food allergies 1-2 bowel movements/day

Nutrition Assessment

IBW: 9.5kg, based on BMI/age at 15th %ile Anthropometrics Date Age Weight Wt/Age Z-score 11/21/16 21 months 8.08 kg -- 5/4/17 28 months 9.10 kg -3.58 5/8/17 8.70 kg -3.99 5/9/17 8.60 kg -4.17 5/10/17 8.81 kg -3.92 5/11/17 IBW: 9.5kg, based on BMI/age at 15th %ile

Average weight gain: +100g/day Anthropometrics On Admission 5/8/17 Most Recent 5/11/17 Weight: 8.7 kg Height: 79 cm BMI: 13.9 BMI z-score: -2.50 Wt/age z-score: -3.99 Ht/age z-score: -2.77 Weight: 9.1 kg BMI: 14.6 BMI z-score: -1.68 Wt/age z-score: -3.86 Average weight gain: +100g/day

Growth Charts Comment on labs

Feeding Regular PO diet as tolerated Encouraged proper eating habits Provided Boost Kids Essentials (BKE) 1.5 240 mL PO TID as tolerated RD provided supplement taste test. Patient preferred Boost Breeze and Ensure Clear. 5/9/17 Initiated overnight NG-tube feeds of BKE 1.5 initially @ 10mL/hr and advance by 5 mL/hr q 2hrs towards goal of 35 mL/hr X 10 hrs to meet ~66% of estimated energy needs. At goal rate on 5/10/17

Calorie Count 5/9/17 5/10/17 420 mL, 131 kcal/kg PO (food and formula)

Nutrition Needs Kcals (90kcal/kg) Protein (1.2 pro/kg/day) Fluid (100mL/kg) Catch-up Growth Eq: (IBW (kg) X DRI for age)/actual wt Fluid needs are based on the Holliday-Segar method Estimated Kcal/kg/day: (9.5kg X [82 kcal/kg])/8.7kg = 90kcal/kg Estimated Pro/kg/day:(9.5kg X [1.05 g/kg])/ 8.7 = 1.15g pro/kg/day (100mL/kg/day) Estimated Calories/day = 90kcal/kg X 8.7kg = 783kcal Estimated g Protein/day = 1.2 g pro/kg/day X 8.7kg = 10.01 gm/day 100mL/kg/day X 8.7kg = 870mL/day

Nutrition Diagnosis [E44.0] Moderate Malnutrition related to inadequate energy intake as evidenced by FTT, BMI 13.9, z-score: -2.50.

Plan of Care

Plan Encourage regular PO intake and eating habits Do not imitate eating habits of others or stop eating when they stop eating Provide Boost Kids Essentials (BKE) 1.5 240 mL PO TID as tolerated. RD provided supplement taste test. Patient preferred Boost Breeze and Ensure Clear. Celiac, urine, and sweat test all performed. Results were normal. 5/9/17 Initiated overnight NG-tube feeds of BKE 1.5 initially @ 10mL/hr and advance by 5 mL/hr q 2hrs towards goal of 35 mL/hr X 10 hrs to meet ~66% of estimated energy needs. At goal rate on 5/10/17 Patient will continue overnight NG tube feeds at home.

Discharge Plan 5/12/17 Recommend eating a high-calorie diet throughout the day. Aim to eat at least 3 meals and 2-3 snacks per day. Continue to drink high-calorie supplements at least 2-3 times per day (including Ensure Clear, Boost Breeze, Pediasure, etc) Continue overnight feeds through the NG tube of Boost Kids Essentials 1.5 at a rate of 35 mL/hr over 10 hours while he sleeps. 25-Hydroxy level: 18, which is low. Recommend vitamin D supplement. Recommend GI outpatient follow up.

Summary

Summary Nutrition Implications of Failure to Thrive Growth pattern Morbidity, mortality, developmental delay Medical or social factors Growth pattern 5/4/17 9.1kg D/C on 5/12 at 9.1 kg Demonstrated weight gain while inpatient NG tube feeds/supplements at home

THANK YOU! To every RD at Children’s, especially Brittany Cines, Laura Hashiguchi, and Meredith Dillon for mentoring me during this rotation, and my director, Phyllis McShane for providing me with this opportunity!

References World Health Organization. WHO Child Growth Standards: Length/Height-for-Age, Weight-for-Age, Weight-for-Length, Weight-for-Height and Body Mass Index-for-Age: Methods and Development. Geneva, Switzerland: World Health Organization; 2006 CNMC GI Team Standards of Practice http://www.healthline.com/symptom/failure-to-thrive https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3195791/