1. FAILURE TO THRIVE By
William Bithoney
Patrick Casey
Robert Karp S U

2. Failure to Thrive Abnormal weight status during infant-toddler years
and/or
Abnormal weight gain
(weight growth velocity)

3. Abnormal weight status Referenced against:
Genetic growth expectations for family
Children of same gender and gestation adjusted age
<5% on NCHS curves
Child's own length
<10-25% on NCHS curves

4. Abnormal weight gain (Growth Velocity)
Falling across two standard deviation percentile lines on NCHS curves over 6 month period
For at least one to two months

5. FTT Definition includes:
"light"
"thin"
atypical weight gain

6. Cautions Regarding Definition of Failure-to-Thrive
Genetically small due to parents size
Children born small for gestational age (SGA) may never catch up
If born larger than long-term genetic potential demonstrate decreased growth rate in first 2 years

7. FTT Definition: Growth Only
Not necessarily associated with developmental/emotional problems in child
Not necessarily environmental causation

8. What's in a name? Growth Delay Growth Failure Failure to Grow
Growth Deficiency
Failure to Gain Weight

9. FTT of long duration (Grown Older)
STUNTED:
Abnormal length and head circumference
Psychosocial Dwarf?

10. Failure-to -thrive Cause:
All children with Failure-To Thrive
are
Undernourished

11. Three Methods to Categorize Undernutrition in Children
McLaren,
Read:
% median
wt/ht
for age ratios
>90
85-90
75-84
<75
Gomez:
% median
weight-
for age
>90
75-90
60-74
<60
Waterlow:
% median
weight-
for-height
>90
80-90
70-79
<70
Degree of
Under-
Nutrition
None
Mild
Moderate
Severe

12. Categorization of Undernutrition in 258 Children Referred for "Failure to Thrive"
McLaren,
Read
No. 18 38
156 46
Degree of
Under-
Nutrition
None
Mild
Moderate
Severe
Gomez
No. 5
132
112 9
Waterlow
No. 64
149 42 3 % 2 51 43 4 % 25 58 16 1 % 7 15 60 18

13. Clinical Subtypes I. Medical Cause II. Clinical Presentation
Organic vs. Non-organic vs. Mixed
II. Clinical Presentation
Age of onset
Severity
Chronicity

14. Non-organic Etiology:
medical disease present and clinically judged to be sole cause of FTT
Non-organic Etiology:
problems in the child's environment judged to be the primary cause of FTT, in the presense or absence of medical disease
MIXED Etiology:
medical problem and problems in environment in combination are judged to be cause of FTT

15. Problems with Organic/Non-Organic Dichotomy
1. It is often difficult to place a child in either category
2. The dichotomy fails to account for the compounding effect of problems in both the child and the environment

16. Problems with Organic/Non-Organic Dichotomy (Cont'd)
3. Children with either may have symptoms like diarrhea or vomiting
4. Children with either may gain weight while in the hospital
5. Global terminology is not specific enough to develop an individualized management plan

17. Clinical Subtypes (Cont'd)
III. Socioemotional
0-3 months
4-10 months
11-36 months
Homeostasis
Attachment disorder
Separation
individuation disorder

18. Clinical Subtypes (Cont'd)
IV. Psychiatric Diagnoses
Feeding Disorder
Depression
Reactive Attachment Disorder
V. Mechanical Feeding Disorder
Food Avesion

19. Transactional FTT
Multiple aspects (overt or subtle) of child, parents, and the proximal and distal environments interact across time to result in FTT.

20. Final Diagnosis of 131 Cases of Failure to Thrive
Number 59 46 22 4
Percent 45 35
16.7
3.3
Non-organic
Interactional
Organic
Unknown

21. Frequency of Organic Systems Causing Failure to Thrive
Gastrointestinal
Neurological
Respiratory-Pulmonary
Cardiovascular
Endocrine
Other
Most Common
Least Common

22. Prevalence of Failure to Thrive
3.5% of admissions to children's hospitals
10% of clinic visists in urban and rural outpatient settings
up to 16% 0-4 year olds in low income populations are "stunted"

23. Failure to Thrive
Weight is abnormally 2 standard deviations below the mean for gestation corrected age -- and/or
weight crossess percentile curves by two standard deviations
weight to height ratio is depressed

24. "My baby is just small for her age"
-Parent

25. Failure to Thrive: Spectrum of Causes
Problem in
the Child
ORGANIC
Problem in the
Environment
NON-ORGANIC
Interactive
Effects

26. Parent Functioning Child Outcomes Development Learning Behavior Growth
Health

27. Goals of Clinical Evaluation
Identify conditions which:
1. Negatively affect growth potential (disease)
2. Increase basic caloric needs (e.g. chronic infection)
3. Decrease availability/utilization of calories (e.g., malabsorption)
4. Negatively affect parents ability to meet nutritional needs (can't/won't eat)

28. Diagnostic Evaluation
1. Growth assessment
confirm the diagnosis with weight and height, present and past
2. History
predisposing factors
3. Physical examination
significant findings other than malnutrition

29. Diagnostic Evaluation (Cont'd)
4. Development-Behavioral Assessment
Assess delays in cognitive, language, or motor functioning
Identify any behavioral abnormalities
5. Laboratory Evaluation
Varies for each child
Stepwise approach is recommended

30. Laboratory Evaluation
Should be directed by findings from the history and physical examination
Document nutritional status:
albumin, iron, zinc
Child may have endemic problem:
Tbc, AIDS, giardia

31. Diagnostic Evaluation (Cont'd)
6. Nutritional and Feeding Evaluation
Content and structure of mealtimes
Feeding techniques
7. Social History
Identify parental/family strengths and weaknesses

32. Diagnostic Evaluation (Cont'd)
8. Parent/Child Interaction
Especially as it relates to feeding
9. Psychiatric Evaluation
Important if the caregivers emotional state is adversely affecting parent-child interaction

33. Hospitalization vs. Outpatient Care
Advantages of hospitalization:
Able to observe and control feeding
Able to observe the parent-child interaction
Medical evaluation can be done easily
Disadvantages of hospitalization:
Cost
Child (and parent) are away from their normal environment

34. Indications for Hospitalization of Children with Failure-to-Thrive
1. Evidence of physical abuse
2. Extreme failure to thrive (starvation)
3. Extremely dysfunctional parent-child relationship or family
4. When distance and transportation issues mean outpatient management is not practical
5. When outpatient management has failed

35. Management of the Child with Failure-to-Thrive
1. Nutritional asessment and intervention
2. Improved parent-child interaction
3. Developmental stimulation
4. Treatment/management of medical conditions
5. Support and intervention for social and family problems
6. Mental health referrals where indicated
7. Regular follow-up care

36. Best Predictors of Prognosis
Age of onset, chronicity
Ongoing quality of the home environment

37. Interactional Model of Failure-to-Thrive
PARENT
Economic Status
Health
Knowledge
Emotional State
Past Experience
CHILD
Appearance
Neuro developmental maturity
Ease of Caregiving
Parent-Child Interaction
Failure-to-Thrive
Endocrine-Cellular
Dysfunction
Nutritional
Deficiency

38. Environmental Characteristics: Supports and Stressors
Home
-Marital Relationship
-Physical Quality
-Organization
-Stability
-Economic Resources
Family
Neighborhood and Work