1. 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

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

3. Overview of Condition

4. 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.

5. Meet ZS

6. 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

7. Nutrition Assessment

8. 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

9. 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

10. Growth Charts
Comment on labs

11. Feeding Regular PO diet as tolerated
Encouraged proper eating habits
Provided Boost Kids Essentials (BKE) 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 mL/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

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

13. 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 = gm/day
100mL/kg/day X 8.7kg = 870mL/day

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

15. Plan of Care

16. 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) 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 mL/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.

17. 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.

18. Summary

19. 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

20. 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!

21. 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