March 10, 2011

 Final Common Pathway ◦ Medical ◦ Psychosocial ◦ Environmental  Interaction between ◦ Environment ◦ Health ◦ Development ◦ Behavior

 Definition ◦ Failing to grow at a rate consistent with expected standard for infants and toddlers younger than 3 years of age  Wasting ◦ Decreased weight for height ◦ Signals acute malnutrition ◦ Decreased subcutatneous fat  Stunting ◦ Decreased height for age ◦ Sign of chronic undernutrition

 Organic ◦ Medical disorder interfering with growth  Malabsorptive disorders  Genetic syndromes  Endocrine disorders  Neurologic dysfunction

 Nonorganic ◦ Diagnosis of exclusion ◦ Environmental conditions ◦ Specific examples  Oromotor dyspraxia  Sensory-motor disorder  Feeding disorder of infancy  Family relationship problem  Child neglect  Mental disorder of parent  Multifactorial ◦ Combination of multiple factors

 Prevalence ◦ Low weight for age  4.1% ◦ Low weight for height  2.5%  Risks ◦ Poverty ◦ Food insecurity ◦ Larger family size ◦ History of child abuse

 Pathogenesis ◦ Loss of calories through malabsorption ◦ Increased caloric expenditure  Hyperthyroidism, CHD, chronic pulmonary disease ◦ Inadequate intake of calories  Most common

 Presentation ◦ Family is concerned that their child is not growing as well as other children of the same age ◦ Family reports that the child is feeding poorly ◦ Physician notices on PE or growth charts

 Evaluation ◦ Complete History  Including complete review of systems  Nutritional history  Feeding behavior history  Documentation of parent-child patterns  FH  SH  History of height and weight trajectories of parents and siblings

 Growth chart ◦ Most important ◦ Growth velocity  Physical exam ◦ Neurodevelopmental status

 Lab tests ◦ Few tests are recommended ◦ Based on positive findings from history and physical exam ◦ Non-response to dietary therapy ◦ Routine  Iron deficiency  Lead poisoning  TB  Chronic UTI

 Address nonmedical problems ◦ Mental health disorders ◦ Child maltreatment ◦ Feeding disorders ◦ Positive reinforcement and pediatrician support are key  Address medical problems  Severe issues ◦ Intense therapy ◦ G-tube feedings

 Prognosis ◦ Most show improvement with dietary intervention  Some will show improvement without intervention as development progresses ◦ “Picky eaters” in childhood  Some may have anxiety disorders or autistic spectrum disorders ◦ Cognitive and school outcomes are worse  May be influenced by other environmental factors as well