1. BY DR.RANDA AL-GHANEM PEDIATRIC GI CONSULTANT FAILURE TO THRIVE

2.  DEFINITION: - GROWTH BELOW 3RD OR 5 TH PERCENTILE IN GROWTH CHART. - OR IF INFANT OF CHILD HAS GOT SIGNIFICANTLY LESS GROWTH THAN PEERS.

3.  CAUSES:  NON ORGANIC (70%): 1. LOW BIRTH WEIGHT ( 5-10 %) OF THEM HAVING F.T.T 2. POVERTY (POOR PEOPLE). 3. FAMILY DISORDER. 4. PSYCHO-SOCIAL REASON(STRESS,CHILD ABUSE)

4.  CAUSES:  ORGANIC (30%): UNDER LINING DISEASE SUCH AS: 1. GIT: GER,CELIAC,LACTATE INTOLERANCE, HEPATITIS, LIVER CIRRHOSIS,CLEFT LIP AND PALATE, IBD, MALABSORPTION,MILK PROTIN INTOLERANCE. 2. RENAL:UTI, DIABETES INSIPIDUSE,CHRONIC RENAL INSUFFICIENCY. 3. CARDIAC: CONGINITAL HEART DISEASES

5.  CAUSES:  ORGANIC (30%): CONT,,, 4. RESPIRATORY: ASTHMA, BPD, UPPER AIR WAY ANOMALLY,C.F 5. ENDOCRINE: HYPOTHYROIDISM,DM,GROWTH HORMONES DIFICIENCY 6. INFECTION: HUMAN IMMUNO-DIFICIENCY, T.B, BACTERIAL INFECTION OF GIT.

6.  CAUSES:  ORGANIC (30%): CONT,,, 7. METABOLIC: INBORN ERROR OF METABOLISM. 8. CONGINITAL: CHROMOSOMAL ABNORMALITY,PERINATAL INFECTION. 9. NEUROLOGICAL: M.R, DEGENERATIVE BRAIN DISORDER, CEREBRAL PALSY. 10. OTHERS: LEAD POISONING,MALIGNANCY,COLLAGEN VASCULAR DISEASE, RECURRENT ADINOIDS AND TONSILES INFECTION, GONADAL DYSGENISIS.

7.  HOW TO APPROACH CHILD WITH F.T.T:  DEPEND ON: AGE SIGNS AND SYMPTOMS.

8. AGE: FROM BIRTH TO 3 MONTHS 1. PSYCHO-SOCIAL F.T.T (MOTHER). 2. PERINATAL INFECTION. 3. GER 4. INBORN ERROR OF MTABOLISM 5. SO BABY WILL HAVE VOMITING,SPITTING,FOOD REFUSAL AND DIARRHEA.

9. FROM 3-6 MONTHES: 1. HIV 2. PSYCHO-SOCIAL F.T.T(MOTHER) 3. C.F 4. MILK PROTIN INTOLERANCE 5. RENAL TUBULAR ACIDOSIS 6. SO PATIENT WILL HAVE RECURRENT INFECTIONS,NIGHT COUGH,VOMITING,ASPIRATION,ASTHMA AND FATTY STOOL.

10. FROM 7 MONTH AND ABOVE: 1. CELIAC DISEASE 2. GER 3. RENAL TUBULAR ACIDOSIS 4. DELAY INTRODUCTION OF SOLID FOOD 5. CEREBRAL CAUSES 6. TONSILLAR HYPERTROPHY AND SLEEP APNEA

11.  CLINICAL PRESENTATION: - RANGE FROM MILD TO SEVER. - FROM JUST LOSS OF WEIGHT TO ALOPECIA OR LOSS OF SUBCUTANEOUS FAT, DERMATITIS, RECURRENT INFECTIONS, MARASMUS AND KWASHIORKOR.

12.  HOW TO MEASURE DEGREE OF F.T.T: BY CALCULATING GROWTH PARAMETERS ( WIAGHT, HIGHT, WT/HT RATIO) AS % OF MEDIAN VALUE FOR AGE BASED ON GROWTH CHART. MILDMODERATESEVER WIEGHT75-90%60-74%LESS THAN 66% HIGHT90-95%85-89%LESS THAN 85% WT/HT81-90%70-80%LESS THAN 70%

13.  N.B: WIEGHT FOR AGE DECREASE EARLY FOLLOWED BY DECREASE HIGHT.  BUT,,, IN CHRONIC MALNUTRTION,WIEGHT AND HIGHT REDUCED TOGETHER, SO THEY HAVE NORMAL WIEGHT FOR HIGHT.

14.  DIAGNOSIS: DEPENDS ON HISTORY,EXAMINATION, OBSERVATION OF PARENTS (CHILD INTERACTION AND THEY GIVE THE CHILD ENOUGH CALORIES, IF THE CHILD DRINK THE MILK GIVEN, POOR KNOWLAGE OF PARENTS, DEPRESSED PARENTS, ETC… POVERITY,IF CHILD SLEEP FOR LONG TIME NOT TAKING ENOUGH CALOREIS.

15.  EXAMINE INFANT FOR : 1. ANY ANOMALIES,ORAL –MOTOR DYSFUNCTIONS. 2. CARDIO-PULMONARY DYSFUNCTIONS 3. VOMITING,DIARRHEA,FATTY STOOL 4. POLYDYPSIA,HYPERPHAGIA 5. EXAMINE ANY PHYSICAL ABUSE( SIGNS IN THE SKIN)

16.  LAB WORK:  CBC,INFECTION SCREEN, TORCH,THYROID FUNCTION,LEAD LEVEL,URINE ANALYSIS,ELECTROLYTE VALUES  OTHER SPECIFIC STUDY: 1. PH PROBE FOR GER 2. MALABSORPTION TEST 3. ORGANIC AND AMINO ACIDS 4. SWEAT TEST 5. STOOL FOR PH,FAT,REDUCING SUBSTANCE, OCCULT BLOOD,OVA. 1. HIV

17.  TRATMENT: DEPEND ON CAUSES.  INDICATION FOR HOSPITALISATION:  SEVER MALNUTRETION  FURTHER INVESTIGATION NEEDED  LACK OF CATCH UP GROWTH  EVALUATION OF PARENTS-CHILD FEEDING INTRACTION  USUALLY HOSPITALIZATION FROM 10 DAYS TO 2 WEEKS WILL BE ENOUGH.  PARENTS OF ORGANIC F.T.T SHOULD BE INFORMED ABOUT

18.  DIAGNOSIS AND TREATMENT. - PARENTS OF NON ORGANIC F.T.T SHOULD BE EDUCATED ABOUT HIGH CALOREIS INTAK AND HELP IF ANY PSYCHO-SOCIAL PROBLEM (TEAM WORK: DIETITIAN,SOCIAL WORKER,MEDICAL TEAM).

19.  CALORY INTAKE CALCULATED AS: 120 KCAL/KG X (GAOL WT/CURRENT WT)  EXPECTED TO TAKE FROM 1.5 TO 2 TIMES OR NORMAL REQUIRMENT.  ADD TO FURMULA: 1. GLUCOSE POLYMERS, 2. PROTIN 3. INCREASE LIPIDS 4. VIT D AND IRON TO BE GIVEN 5. ZINC 25 MG/DAY ENHANCE GROWTH

20.  FOLLOW UP  MAJORITY OF PATIENT CAN BE TREATED AS O.P.D WITH FOLLOW UP EVERY 2-4 WEEKS THEN EVERY 1-2 MONTH, CATCH UP WILL TAKE 12-18 MONTHS.

21. QUESTIONS ???

22. CASE SENARIO (1) the mother of a 6-month-old girl presents for a well-child check. the baby’s weight and length are at the 5th percentile, and her head circumference is at the 25th percentile. which of the following is a true statement regarding failure to thrive in infants? (a) more common among children (b) extremely rare (c) most often caused by an organic problem (d) more common among female infants than male infants (e) a major risk factor for later developmental and behavioral difficulties

23. CASE SENARIO (2) a3-month-old infant presents with poor growth and inadequate weight gain. there is no history of vomiting or diarrhea. except for the appearance of malnutrition and lack of subcutaneous fat, the physical examination is normal. what is the most likely cause of this child’s failure to thrive? (a) renal disease (b) a metabolic disorder (c) tuberculosis (d) an endocrine disorder (e) a nonorganic cause

24. CASE SENARIO (3) An infant with failure to thrive has rectal prolapse. What test will most likely provide the diagnosis? (A) abdominal CT-scan (B) rectal biopsies (C) liver function testing (D) barium enema study (E) sweat chloride test

25. CASE SENARIO (4) The inpatient pediatric team is discussing the causes of failure to thrive (FTT) as they evaluate a 9-month-old infant with weight and length below the 5th percentile. Which of the following should be included in the differential diagnosis of infant who is not thriving? (A) Small atrial septal defect (B) Acute bacterial meningitis (C) Cystic fibrosis (D) Recurrent otitis media (E) Mild intermittent asthma

26. CASE SENARIO (5) An 8-month-old female is hospitalized with failure to thrive. She has a 1- day history of fever and cough. On physical examination, you observe a very thin, well-hydrated alert infant in no acute distress. You obtain a complete blood count and order a chest x-ray for further evaluation of a one day history of fever and cough. You note the lung fields to be normal but also note an absence of a thymic shadow. Which of the following should be your next step? (A) obtain an immunology consult (B) order genetic karyotyping (C) repeat the chest x-ray in 24 hours (D) order a cardiac ultrasound (E) feed the infant as tolerated, following weight and intake closely

27. CASE SENARIO (6) A2-year-old Caucasian male presents with failure to thrive, chronic diarrhea, and recurrent pneumonia. Though his family history is negative for cystic fibrosis, a sweat test reveals a sodium concentration of 120 mg/dL (high). Which of the following is the appropriate next step in caring for this infant? (A) iron (B) vitamin B12 and folic acid (C) pancreatic enzyme supplementation (D) copper and magnesium (E) parenteral diuretics

28. CASE SENARIO (7) At 1 year of age, a boy was at the 50th percentile for height and weight. At 2 years of age, he is at the 25 th and 10th percentiles respectively. Review of systems reveals fussiness, loose stools, and possibly stomach aches all beginning after the mother stopped breastfeeding the boy and introduced table foods. Mother has consumed milk products lifelong, but her son does not drink cow milk. 9. Which is the most likely cause of these symptoms? (A) toddler’s diarrhea (B) lactose intolerance (C) celiac disease (D) cow milk protein allergy (E) chronic giardiasis

29. CASE SENARIO (8) A 6-month-old male presents with failure to thrive, eczema, and a history of recurrent bacterial infections. On evaluation, a thrombocyte count of 20,000/mm3 is noted. The peripheral smear reveals microthrombocytes. Which of the following is the most likely condition causing these signs and symptoms? (A) Wiskott-Aldrich syndrome (B) 22q11 deletion syndrome (C) celiac disease (D) idiopathic thrombocytopenic purpura (E) leukemia