Telehealth Rounds Friday, April 7th, 2017 Failure to Thrive Telehealth Rounds Friday, April 7th, 2017

Objectives Definition of failure to thrive Review the use of WHO Growth Charts Patterns of normal growth Become comfortable with the differential diagnosis of FTT Develop an approach to the child with failure to thrive When to refer to a pediatrician

Definitions Failure to thrive is can be considered to be a symptom and suggests inadequate caloric intake to meet the child’s requirements Growth curves Crossing more than 2 percentiles Plotting below the 3rd percentile (weight-for-age or weight- for-length) Typically see FTT in children under the age of 2 years The definition is not entirely clear – no consensus – Growth curve definitions are challenging – crossing 2 lines on the WHO curves is a more significant drop and should be evaluated – some children may be persistently on the 3rd or 5th percentile which could be normal for their genetic potential Weight typically decreased before length. HC is typically the last measure to be affected. Weight deceleration is the most common (versus weight loss) The growth TREND is much more important than a single plotted value

Long-term consequences Nutrient deficiency Reduced final adult height Developmental, behavioural and cognitive effects are unclear

WHO Growth Charts The GOLD STANDARD for assessment of growth in children Growth standards based on healthy, well-nourished children 6 different countries Breastfed infants Five percentiles (3rd, 15th, 50th, 85th, 97th) Growth charts are used to regularly plot height, weight and HC (if <2y) – their use helps to identify early concerns with a child’s health (either over or under nutrition) WHO charts have been recommended since 2010 by the CPS (but have been available since 2007) CDC charts should no longer be used (not all children were healthy, US data only, fewer breastfed infants) – used to have 6 percentiles

Normal Growth Intrauterine vs. extra-uterine environment Breastfed vs. formula fed infants Caloric requirements: 100-110kcal/kg/day for the first year Birth weight: Often reflects placental function and the intrauterine environment more than genetic potential Ie: smoking, diabetes, maternal diet, drug use, prematurity, post-dates Extrauterine environment: Regain birth weight by 10-14 days of life BW typically has doubled by 4-6 months Breast fed infant gain weight more rapidly over first 6 months Breastfeeding difficulties are common and can prevent optimal growth Formula fed babies typically gain more weight between 6-12 months of age EBM/Formula = 67kcal/100ml

Differential Diagnosis Inadequate calorie intake Feeding difficulties – ie: ARFID, oral-motor challenges, autism Social factors Poor appetite (ie: Genetic syndromes) Impaired calorie utilization or absorption (ie: malabsorption) Cow’s milk protein allergy Celiac disease Cystic fibrosis Type 1 diabetes Can use a broad categorical approach Calorie intake: Breastfeeding difficulties Improper formula preparation Parental feeding expectations/practices Food insecurity Calorie utilization Celiac disease (usually presents after 1 year of age CF – a negative NBS does not rule it out, not screened for in Quebec patients

Differential Diagnosis (2) Increased metabolic demand Systemic illness (malignancy, CF, CHD, renal disease, BPD) Genetic syndromes (RSS, Turner’s) Intrauterine growth restriction (IUGR)

Patterns of FTT to help with diagnosis Adjusting towards genetic potential Usually both height and weight affected Inadequate caloric intake Weight affected primarily Endocrinopathy Height affected primarily

Approach to FTT History Pregnancy history: growth, gestational age, maternal GDM, HTN, infections, maternal smoking Birth weight Past medical history Developmental concerns Obviously also take a medical history Do a systems-based ROS looking for

Approach to FTT Feeding history (what, when, where) Breast, formula or a combination (frequency, duration, volumes, fdg difficulties) Vomiting, gagging, choking Stools (mucous, blood, frequency, steatorrhea) Feeding behaviours Food allergies Stress related to feeding/eating

Approach to FTT Family History CMPA Food allergies Celiac disease Inflammatory bowel disease, JIA, renal disease Constitutional growth delay Genetic syndromes

Approach to FTT Social History Stressors Parent experience/family values or cultural beliefs Parental mental health Substance use Parental education level Social support system Psychosocial stressors are a major contributor to FTT in children

Review of systems Temperament Sleep Parental attachment/stress Voiding and stooling patterns System-based screen for underlying illness

Approach to FTT Ensure that measurements are accurate and plot them on the WHO growth charts Calculate the midparental height to help determine genetic potential Maternal height (cm) + paternal height (cm) +/- 13cm / 2 Add 13cm if the child is male, subtract 13cm if the child is female Plot the midparental height on the growth chart for children 2-18 years

Physical Exam General appearance Look for features of genetic syndromes Muscle wasting, decreased subcutaneous fat Signs of neglect or abuse Identify signs of chronic disease (ie: heart murmur, abdominal mass, pallor, distended abdomen) Neglect: severe diaper rash, eczema, poor hygiene, bruising, torn frenulum

Investigations Basic investigations CBC, renal and liver panels Iron studies inflammatory markers Albumin TSH Urinalysis Consider in special cases only: Sweat test Bone age Vitamin levels Fecal elastase Serum immunoglobulins Celiac screen HIV serology Step-wise approach to minimize unnecessary testing Use the history and physical to guide you. Often no investigations are require initially Urinalysis for RTA Additional tests: Sweat test for CF Bone age for growth hormone deficiency Vitamin levels for fat malabsorption Fecal elastase for pancreatic insufficiency

Management Optimize nutritional intake Education & reassurance Follow growth closely Additional specialists may be required Psychologist Occupational therapist Optimize nutritional intake Lactation consultant for breastfeeding difficulties Formula supplementation Dietitian consultation Toddler feeding strategies – ’The Division of Responsibility’ Assess patient every 2-3 months until an acceptable growth trend is present, then follow less closely

Management – Behavioural Strategies Structured mealtimes at the table Reduce meal time distractions Allow children to feed themselves Offer a ‘tasting’ menu and then provide additional helpings if the child desires Solids before liquids Positive reinforcement

Pediatric Referral When no etiology can be identified and there is significant growth failure If you suspect a genetic syndrome If you suspect an endocrinopathy When there is significant parental stress and concern

Take Away Points The WHO growth charts are the gold standard for tracking growth Crossing percentiles in growth during the first 2-3 years of age is common but is not typical after 3 years of age The differential diagnosis can be simplified by thinking about inadequate calories in, inadequate absorption or increased metabolic demand The most common cause of FTT is inadequate caloric intake – assessment by a dietitian is almost always helpful The majority of infants and children will require minimal investigations

Resources WHO Growth Curves available online at http://www.dietitians.ca/Dietitians-Views/Prenatal-and- Infant/WHO-Growth-Charts.aspx Dieititians of Canada Handout “Is my child growing well”, available online at http://www.dietitians.ca/getattachment/72c1830d-ea69- 41b7-b12f-b9fccb26745c/ChildGrowth2014_E.pdf.aspx

Questions?

References Position Statement: Promoting optimal monitoring of child growth in Canada: Using the new World Health Organization growth charts. Canadian Pediatric Society. Published June 1, 2010. Accessed online on April 4, 2017: http://www.cps.ca/documents/position/child-growth-charts The toddler who is falling off the growth chart. Canadian Pediatric Society. Published Oct 1, 2012. Accessed online on April 4, 2017: http://www.cps.ca/documents/position/toddler-falling-off-the-growth-chart Failure to thrive: Current Clinical Concepts. Pediatrics in Review (2011). Volume 32, Issue 3. Failure to thrive. Chapter 41. Nelson’s Textbook of Pediatrics, 20th Edition. P 250 -