1. Failure To Thrive Debbie Acker, RN Nurse Service Administrator Division of Protection & Permanency Department for Community Based Services Kentucky Cabinet for Health & Family Services & Melissa L. Currie, MD Board-Certified Child Abuse Pediatrician Director, Division of Forensic Medicine Associate Professor of Pediatrics University of Louisville School of Medicine 7/1/11

2. Objectives To understand the difference between organic and inorganic Failure to Thrive To recognize indicators of Failure to Thrive 7/1/11

3. Failure to Thrive: 1899 …From that time on the child ceased to thrive. He began to lose weight and strength, at first slowly then rapidly, in spite of the fact that every known infant food was tried. 7/1/11

4. Failure to Thrive Failure to thrive lacks a precise definition. It describes a condition rather than a specific disease. Children who fail to thrive don't receive or are unable to take in, retain, or utilize the calories needed to gain weight and grow as expected. The diagnosis of Failure to Thrive is made by a physician. 7/1/11

5. Failure to Thrive Most diagnoses of failure to thrive are made in infants and toddlers in the first few years of life. After birth, a child's brain grows as much in the first year as it will grow during the rest of life. Poor nutrition during this period can have permanent negative effects on mental development. 7/1/11

6. Failure to Thrive Most babies double their birth weight by 6 months and triple it by age 1. Children with failure to thrive often don't meet these milestones. A child who starts out "plump" and who shows signs of growing well can begin to fall off in weight gain. After a while, linear (height) growth may slow as well. 7/1/11

7. Failure to Thrive may present as… A weak, pale, and listless appearance. Instead of smiling, cooing, and maintaining eye contact, the baby stares vacantly with the typical “radar gaze”. The habit of sleeping in a bizarre, curled-up, fetal position, with fists tightly closed. Self-stimulatory behavior, such as rocking back and forth in bed as the baby lays on her back (creating bald patches on the back of the head) or banging her head repeatedly against her crib. Dirt and feces under long, ragged fingernails, severe diaper rash, a dirty face, hands, feet and body. Obvious delays in development and motor function. 7/1/11

8. Organic or Inorganic Organic - caused by an underlying medical disorder Inorganic - caused by caregivers' or parents' actions Doctors are less likely to make a distinction today because medical and behavioral causes often appear together. ◦For instance, if a baby has severe reflux and is reluctant to eat, feeding times can be stressful. The baby may become upset and frustrated, and the caregiver might be unable to feed the child adequate amounts of food. 7/1/11

9. Organic Causes of Failure to Thrive Gastrointestinal system conditions ◦Gastroesophageal reflux disease (GERD)  With GERD, the esophagus may become so irritated that a child refuses to eat because it hurts. ◦Chronic diarrhea  Persistent diarrhea can interfere with the body's ability to hold on to the nutrients and calories from food. ◦Cystic Fibrosis, Chronic liver disease, and Celiac disease.  Cystic fibrosis, chronic liver disease, and celiac disease are mal-absorptive disorders that limit the body's ability to absorb nutrients. 7/1/11

10. Organic Causes of Failure to Thrive A chronic illness or medical disorder ◦A child who has trouble eating may not take in enough calories to support normal growth.  Examples are prematurity or a cleft lip or palate ◦Other conditions that can lead to failure to thrive include cardiac, endocrinologic, and respiratory disorders, which can increase a child's caloric needs so that it becomes difficult to meet them. 7/1/11

11. Organic Causes of Failure to Thrive An intolerance of milk protein ◦This can cause difficulty with absorbing nutrients until it's diagnosed. ◦It can also put an entire class of food out of reach, restricting the child's diet and occasionally leading to failure to thrive. 7/1/11

12. Organic Causes of Failure to Thrive Infections ◦Parasites, urinary tract infections, tuberculosis, etc., can put great energy demands on the body and force it to use nutrients rapidly (and can diminish appetite), sometimes bringing about short- or long-term failure to thrive. 7/1/11

13. Organic Causes of Failure to Thrive Metabolic disorders ◦These can limit the body's capacity to make the most of calories consumed. ◦They might make it difficult for the body to break down, process, or derive energy from food, or cause a buildup of toxins during the breakdown process that can make a child feed poorly or vomit. 7/1/11

14. Inorganic Causes of Failure to Thrive Social factors ◦ Doctors may not identify a medical problem, but may find that the parents are actually causing the failure to thrive.  Some parents inappropriately restrict the amount of calories they give their infants.  They may fear the child will get fat or enforce a limited diet similar to one they follow.  They might not feed the child enough either because of a lack of interest or because of too many distractions in the household, leading to neglect of the child. ◦Living in poverty also can lead to an inability to provide kids with proper nutrition. 7/1/11

15. Importance of the History in FTT One of the most important tools in determining the course of treatment for FTT is a detailed, accurate history. Seek out family members to confirm and gather additional information. 7/1/11

16. Importance of the History in FTT Ask specific questions about the feeding of the infant such as: ◦Is the infant breast-fed? If so, were there any problems? If not, what formula was used? How is it prepared? How often is the child fed? How much is the child fed? ◦How is the infant fed? (Propping the bottle on a pillow in the crib not only suggests a lack of maternal contact but also the possibility that the child is not getting enough food.) ◦How is the infant’s appetite? How does the caregiver know when he or she is full? ◦Has the infant experienced any diarrhea or vomiting? 7/1/11

17. Importance of the History in FTT More specific questions about the infant such as: ◦How large are the infant’s biological parents? ◦Was there any problems with the pregnancy? Was the child born prematurely? Did the mother receive prenatal care? ◦Is the child on any medications? ◦Has the child had any serious illnesses? ◦How often does the infant sleep? Is he or she active during waking hours? ◦Has the child ever had a period of time when weight gain was adequate? ◦What was different then? ◦Was there any change in household composition or caregiver at the time the failure to thrive began? 7/1/11

18. Importance of the History in FTT More specific questions about the infant such as: ◦Have nurses and other hospital staff document the interaction between caregiver and child. ◦Does caregiver respond to child’s cries? ◦Does caregiver change the diaper, feed the child, interact with the child without prompting by hospital personnel? These types of observations help establish the “big picture.” 7/1/11

19. Failure To Thrive Child gained 9 lb in hospital on regular diet. Mother admitted to neglect (nutritional needs) and volunteered to give child up. 7/1/11

20. Failure To Thrive This child has Celiac Syndrome. It is an intestinal mal-absorption syndrome. 7/1/11

21. Failure to Thrive 7/1/11

22. Failure to Thrive 7/1/11

23. Failure to Thrive – 2 weeks later 7/1/11

24. Failure to Thrive 2 month old with FTT 3 weeks after foster placement 7/1/11

25. Foster placement 7/1/11

26. Failure To Thrive 7/1/11

27. Failure To Thrive 7/1/11