FAILURE TO THRIVE  An infant whose physical growth is recognizably less than that of his peers. Weight 3rd centile … deviation from true centile (max. centile achieved between 4-8 weeks of age) crossing two or more centile lines and persisting for more than a month. Weight 3rd centile … deviation from true centile (max. centile achieved between 4-8 weeks of age) crossing two or more centile lines and persisting for more than a month. Failure to maintain adequate growth velocity age 5 months ~ 90 days. Failure to maintain adequate growth velocity age 5 months ~ 90 days.

For prematures correct until: 18 months for head circumference. 24 months for weight. 40 months for height. Anthropometric indices of F.T.T. W/H weight for height - acute nutritional deprivation W/H weight for height - acute nutritional deprivation W/A weight for age + H/A height for age - chronic malnutrition W/A weight for age + H/A height for age - chronic malnutrition W/H + H/A acute malnutrition superimposed upon chronic malnutrition. W/H + H/A acute malnutrition superimposed upon chronic malnutrition.

F.T.T F.T.T In disadvantaged areas ~ 20% of children In academic pediatric hospitals ~ 5% of admissions Children with birth weight < Kg : Children with birth weight < Kg : constitute 10% - 40% of F.T.T children but only ~ 7% of general population. constitute 10% - 40% of F.T.T children but only ~ 7% of general population.

History IUGR IUGR Symmetric Asymmetric weight < height and head circ. Better prognosis for later growth Intrauterine infections Chromosomal aberrations Prenatal exposure to alcohol, opiates, anticonvulsants

Symptoms Vomiting: Vomiting: anatomic anatomic metabolic (galactosemia, organic acidemia, urea cycle defects, …) metabolic (galactosemia, organic acidemia, urea cycle defects, …) Poor feeding, lethargy: (organic acidemia, uremia, renal tubular acidosis, urea cycle defects….) Poor feeding, lethargy: (organic acidemia, uremia, renal tubular acidosis, urea cycle defects….) Feeding difficulties: cardiac Feeding difficulties: cardiac respiratory (laryngomalacia, T-E fistula…) respiratory (laryngomalacia, T-E fistula…)

Symptoms (cont.) Diarrhea: - since birth (glucose-galactose malabsorption, cong. microvillus atrophy, cong. chloridorrhea….) Diarrhea: - since birth (glucose-galactose malabsorption, cong. microvillus atrophy, cong. chloridorrhea….) - post infectious - post infectious - following weaning - following weaning + other symptoms, e.g + other symptoms, e.g respiratory (cystic fibrosis, immune def. ) respiratory (cystic fibrosis, immune def. ) recurrent infections (immune deficiency..) recurrent infections (immune deficiency..) Chronic or recurrent infections skin, ears, lungs Chronic or recurrent infections skin, ears, lungs

Physical exam Growth curves Growth curves Dysmorphic features Dysmorphic features Microcephaly Microcephaly Eyes Eyes Cardiac anomalies Cardiac anomalies Hepatosplenomegaly Hepatosplenomegaly Hair Hair Odor Odor

 Extensive lab. testing unlikely to contribute to a diagnosis of an organic cause not already suggested by the history and physical exam. Hospitalized F.T.T infants average ~ 40 lab. tests and radiographs. Fewer than 1% of these tests show an abnormality helpful in making a specific diagnosis. Hospitalized F.T.T infants average ~ 40 lab. tests and radiographs. Fewer than 1% of these tests show an abnormality helpful in making a specific diagnosis. - CBC, serum electrolytes, protein, cholesterol, - urinalysis + culture - stool parasites - blood gases, urine pH - sweat test - CBC, serum electrolytes, protein, cholesterol, - urinalysis + culture - stool parasites - blood gases, urine pH - sweat test

 30% - 60% of children undergoing evaluation because of inadequate growth have no apparent organic basis for their growth failure. In all cases of non-organic F.T.T and in many cases of organic F.T.T the primary biologic insult is malnutrition. In all cases of non-organic F.T.T and in many cases of organic F.T.T the primary biologic insult is malnutrition.

Non-organic F.T.T Inadequate caloric intake - Insufficient provision Inadequate caloric intake - Insufficient provision neglect neglect errors in preparation of formulas errors in preparation of formulas “health” diets “health” diets - Excessive intake of low-calorie fluids - Excessive intake of low-calorie fluids - Strict elimination diets - Strict elimination diets post infectious “starvation” post infectious “starvation” low fat diets low fat diets Poor mother- infant interaction Poor mother- infant interaction

To achieve optimal catch-up growth: caloric + protein intake for age X caloric + protein intake for age X vitamins, iron, zinc vitamins, iron, zinc Avoid high intakes during initial re-feeding period ( vomiting, diarrhea) Avoid high intakes during initial re-feeding period ( vomiting, diarrhea) - small frequent feeds, slow increase - small frequent feeds, slow increase - continuous nasogastric drip feeding - continuous nasogastric drip feeding - enriched foods, ad - lib - enriched foods, ad - lib Initial weight gain : after 2-3 weeks Initial weight gain : after 2-3 weeks To restore weight for height : months To restore weight for height : months Catch up in height lags behind that in weight Catch up in height lags behind that in weight