Failure to Thrive Dr Usha Mallinath Dr Richard Mones

Definition  Wt below 3 rd centile  Wt drops 2 major centiles  Wt for length below 3 rd centile  Wt < 80% ideal wt for age

Historic classification  Organic: those for which there is a clear genetic, medical, or anatomic etiology, a very large differential  Nonorganic: insufficient emotional or physical nurturing without pathophysiological abnormality

Calories, Calories  Root of growth failure stems from inadequate calories  Inadequate intake  Increased demands  Poor absorption  Infants require approximately kcal/kg/day  At age 1 year, 100 kcal/kg/day

Normal Weight Gain AgeMean Daily weight gain 0-3 m26-31g 3-6 m17-18g 6-9 m12-13 g 9-12 m9 g 1-3 yr7-9g 4-6yr6g

Epidemiology  1-5% tertiary hospital referrals  5% in 2006 in USA, CDC  High incidence poverty, low socio- economic status  50% not identified by health care professions  Non organic FTT common in females

Pathogenesis  Insufficient food intake  Increase Energy Requirement  Malabsorption

Pathogenesis Insufficient food intake  Inadequate amount of food provided or available  Structural causes of poor feeding e.g. cleft palate, Treacher-Collins  Anorexia of chronic disease

Pathogenesis Malabsorption /Steatorrhea  Celiac disease  Chronic Liver disease  Cystic Fibrosis  Chronic diarrhea

Pathogenesis Increase Energy Requirement  HIV  Congenital Heart disease  Hyperthyroidism

Etiology system based  GI  RS  CVS  Renal  ID  Genetic  Heme/Onc  Endocrine

GI Causes Feeding disorders Diarrhea Cleft palate Infectious Dentition Malabsorption oro-motor Vomiting Hepatic Biliary atresia GERD Chronic Hepatitis Stricture Cirrhosis

Pulmonary  CF  BPD  Tonsilar/ Adenoidal hypertrophy

Endocrine  Hypothyroid  Rickets  DM  GH deficiency  Adrenal insufficiency

Cardiac Causes  Congenital cardiac disease/CHF  POOR INTAKE  ? Increased metabolic demands  Possible fluid restrictions  Early interventions which may interfere with development of normal suck/swallow coordination

ID  HIV  TB  Parasites

Heme/Onc  Classic B-symptoms include  weight loss  anorexia

Genetic  Chromosomal abnormalities  Trisomy 13, 18, 21  Deletion of chromosome 22  Gonadal dysgenesis (45,X), etc  Evaluate for dysmorphisms

Renal  Renal Tubular Acidosis  Disorder of HCO3 and H+ reabsorption in renal tubules  Urine pH >5.5 in light of systemic acidosis

Diagnostic Classification of causes: inadequate Nutrition Intake  Not enough food offered  –Food insecurity  –Poor knowledge of child's needs  Poor transition to table food  Avoidance of high-calorie foods  –Formula dilution  –Excessive juice  –Breastfeeding difficulties  –Neglect  Child not taking enough food  –Oromotor dysfunction  –Developmental delay  –Behavioral feeding problem  Altered oromotor sensitivity  Pain and conditioned aversion  Emesis  –Gastroesophageal reflux  –Malrotation with intermittent volvulus  –Increased intracranial pressure

Malabsorption  Cystic fibrosis  Celiac disease  Food protein insensitivity or intolerance

Increase Metabolic demands  Insulin resistance (eg, intrauterine growth restriction)  Congenital infections (eg, human immunodeficiency virus, TORCH)  Syndromes (eg, Russell-Silver, Turner, Down)  Chronic disease (eg, cardiac, renal, endocrine)

Evaluation  Clinical History  Complete Physical Examination  Judicious Lab tests and other inv

History  Birth : IUGR,LBW,Prematurity, prenatal exposure alcohol, drugs  Chronic diseases  Recurrent infections  Frequent injuries  Review of systems

Feeding history  Kind, amount of formula  Preparation of formula  Excessive low calorie liquid/fruit  Stool pattern, vomiting with feeding  Special diet, vegetarian  Breast feeding techniques  CALORIE COUNT

Feeding history  Feeding environment  Feeding behaviour/interactions

Family history  Family members’ heights and weights  History of illness  Developmental delay  MID-PARENTAL HEIGHT  FAMILY GROWTH TREE

Psychosocial History  Financial & Employment status  Parental depression  Substance abuse  Family discordance /stress  Maladaptive parental styles

Physical Examination  Begin with measurements – if all parameters are <5th percentile, 70%chance of organic etiology  Need to follow pattern of growth (i.e.,isolated points are meaningless)  Dysmorphism  Palate intact  Hypotonia or spasticiy  Signs of neglect (diaper rashes, impetigo,  poor hygiene, protuberant abdomen)

Laboratory evaluation  Guided by clinical evaluation  No evidence extensive screening lab tests  Sever malnutrition: albumin, alkaline phosphatase, calcium, phosphorous  Diagnostic imaging studies based on clinical evaluation

Diagnosis FTT

Treatment  Nutrition Repletion  Treatment of underlying disease  Assessment oromotor function  Food intake % recommended intake

Treatment  Increased food intake; high calorie formula  Enrichment of food: supplementation with minerals and protein  Tube feeding/parentral feeding

Treatment  Addressing psychosocial stresses  Development and behavioral assessment  Child protection services

Hospitalization  Severe malnutrition  Significant dehydration  Serious intercurrent illness or significant medical problems  Psychosocial circumstances that put the child at risk for harm  Failure to respond to several months of outpatient management  Precise documentation of energy intake  Extreme parental impairment or anxiety  Extremely problematic parent-child interaction  Practicality of distance, transportation, or family psychosocial problems preclude outpatient management

Refeeding syndrome  Unknown pathology  Post nutrition rehabilitation in severe malnourishment  Changes in electrolytes( low phosphate, Mg,K)  Disruption fluid balance, edema  Impaired Heart function, hypoglycemia  Prevention by increased K, Phos,Mg during repletion  Montiore blood sugar,electrolytes,blood gases, wt,U/A

Sequelae  Early onset FTT, persistent reduction in Wt, Ht  Long term adverse effects cognition, learning, behavior