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Failure to Thrive

ADEPOJU , V.A 17th Aug, 2011

Overview

Definition Introduction Risk factors Classification Etiology D/D&Diagnosis Investigations & Management Outcome &Prognosis Top 6 things to remember about FTT

Failure to Thrive (FTT):

Definition

Weight below the 5th percentile for age and sex Weight for age curve falls across two major percentile lines Sub optimal weight gain and growth in infants and toddlers Remember 3% normal kids fall below 3rd centile

Other definitions exist, but are not superior in predicting problems (Kirkland 2006)

Introduction

Failure to thrive (FTT):

A sign that describes a problem rather than a diagnosis Usually describes failure to gain wt

Underlying cause is insufficient usable nutrition to meet the demands for growth Approximately 25% of normal children will have a shift down in their wt curve of up to 25%, then follow a normal curve -- this is not failure to thrive

In more severe cases length and head circumference can be affected

Introduction

Specific infant populations Premature/IUGR wt may be less than 5th percentile, but if following the growth curve and normal interval growth then FTT should not be diagnosed Modified growth charts exist for specific populations

Risk Factors

These Can Be Subdivided Into Characteristics Of: The Child The Parent The Society
(Nelson 2004)

Child Characteristics

Some helpful features include: Mental alertness to surroundings - at the extreme described as frozen watchfulness Absent exploration but sustained vigilance Increased appetite and disturbed feeding behaviors Forming indiscriminate attachments in hospital Seeking attention Demonstrating aggressiveness Immature play Decreased inter-personal interaction Dull, pale skin Physically apathetic The mentally handicapped may be at greater risk of abuse

Parental Characteristics

These are generalizations, but helpful features may be as follows: Low intellect combined with lack of knowledge, judgement and motivation Severe depression/neurotic disorders Angry, hostile mothers who feel persecuted by infants Chaotic lives and relationships Chronic medical problems Substance abuse (Nelson 2004)

Socio-cultural Factors
These are generalisations, but there can be interactions of: Parental isolation Poor parental functioning Lack of resources - for example poverty

Cultural understanding of what is appropriate (Nelson 2004)

Classification

Historically has been divided into organic and nonorganic causes


Most cases have mixed etiologies This classification system is out of favor

More useful classification system is:


Inadequate caloric intake Inadequate fat or carbohydrate absorption Increased energy requirements (Nelson 2004)

Etiology

Inadequate Caloric Intake


Incorrect preparation of formula Poor feeding habits (ex: too much juice) Poverty Mechanical feeding difficulties (reflux, cleft palate, oromotor dysfunction) Neglect

Physicians are strongly encouraged to consider child abuse and neglect in cases of FTT that dont respond to appropriate interventions*

Etiology

Inadequate absorption
Celiac disease Cystic fibrosis Milk allergy Vitamin deficiency Biliary Atresia Necrotizing enterocolitis (Nelson 2004)

Etiology

Increased metabolism

Hyperthyroidism Chronic infection Congenital heart disease Chronic lung disease

Other considerations

Genetic abnormalities, congenital infections, metabolic disorders (storage diseases, amino acid disorders)

Aetiology:Syndromes
There Are A Massive Number Of Syndromes Which Result In Failure To Thrive. They Include:
Down's Syndrome Foetal Alcohol Syndrome Congenital Infections Skeletal Dysplasias Turner's Syndrome Bartter's Syndrome

Aetiology: Serious Chronic Disease


These include: Cerebral palsy Hepatic failure Renal failure Degenerative disorders

Vomiting

Indicator of general infection Pyloric stenosis Gastro-oesophageal reflux Hiatus hernia Oesophageal incoordination UTI

D/Diagnosis

The first consideration in an infant presenting with presumed FTT is identifying normal variants of growth. Within this group lie four main patterns infants who have small parents and are growing to their genetic potential infants with constitutional delay in growth

D/Diagnosis

infants born prematurely who are growing below their age matched peers, and infants with postnatal catch down growth (Kane 2003)

Diagnosis

Accurately plotting growth charts at every visit is recommended* Assess the trends H&P more important than labs
Most cases in primary care setting are psychosocial or nonorganic in etiology

History

Dietary

Keep a food diary If formula fed, is it being prepared correctly? When, where, with whom does the child eat?
Illnesses, hospitalizations, reflux, vomiting, stools? Who lives in the home, family stressors, poverty, drugs? Medical condition (or FTT) in siblings, mental illness, stature? Substance abuse? postpartum depression?

PMH

Social

Family

Pregnancy/Birth

Physical

Accurate measurement of childs height, weight, head circumference

Single data point has limited usefulness

Evaluate for dysmorphic features Mouth, palate Neurologic exam


Signs of spasticity or hypotonia

Cardiovascular/Lung exam

Physical

Signs of neglect or abuse


Lack of age appropriate eye contact, smiling, vocalization, or interest in environment Chronic diaper rash Impetigo Flat occiput Poor hygeine Bruises Scars

Physical

Observe parent-child interactions


Especially during a feeding session

How is food or formula prepared? Oral motor or swallowing difficulty? Is adequate time allowed for feeding? Do they cuddle the infant during feeds? Is TV or anything else causing a distraction?

Unless suggested by H&P, no routine lab tests recommended initially*

Lab Evaluation

If problem persists, could consider:

One study of hospitalized pts resulted in only 1.4% of tests being of diagnostic assistance in FTT CBC and film, U/A, Electrolytes, TSH, ESR, Lead, HIV, Tb

If not improving with adequate diet, consider:

Stool for fat, reducing substances, pathogens Celiac antibody testing CF testing, Creatinine and electrolytes, plus liver

and bone function Thyroid function and other endocrine investigations Sweat test,serum ferritin,B12&folate as indicated.Chromosomoal studies

Management

Goal is catch-up weight gain Most cases can be managed with nutrition intervention and/or feeding behavior modification (Bauchner 2004) General principles:
High Calorie Diet Close Follow-up

Keep a prospective feeding diary-72 hour Assure access to food programs, other community resources

Management

Energy intake should be 50% greater than the basal caloric requirement

Concentrate formula, add rice cereal to pureed foods Add taste pleasing fats to diet (cheese, peanut butter, ice cream) High calorie milk drinks (Pediasure has 30 cal/oz vs 19 cal per oz in whole milk) Multivitamin with iron and zinc

Management

Parental behavior
May need reassurance to help with their own anxiety Encourage, but dont force, child to eat Make meals pleasant, regular times, dont rush May need to schedule meals every 2-3 hours Make the child comfortable Encourage some variety and cover the basic food groups Snacks between meals

Management

Do you hospitalize?
Necessary Consider if:

the child has failed outpt management FTT is severe


Medical emergency if wt <60-70% of ideal wt Hypothermia, bradycardia, hypotension

safety is a concern

Management

For difficult cases:


Multidisciplinary team approach produces better outcomes

Dietitians Social workers Occupational therapists Psychologists

NG tube supplementation may be necessary

Outcomes and Prognosis

Persistent disorders of growth


6 of 7 studies showed statistically significant persistent poor growth (ht, wt, hc) in FTT group at up to 5 years from initial treatment.

Earlier intervention leads to better outcomes (Krugman & Dubowitz 2003)

Outcomes and Prognosis

FTT and Immunologic/Infectious Outcomes


FTT children have significantly increased susceptibility to infection (Kane 2003)

Among hospitalized children increased rates of bacteremia and mortality Increased rates of upper and lower respiratory infections

Outcomes and Prognosis

Concurrent Behavior disorders


FTT groups scored lower on reports describing affect and communications skills

Behavior disorders at follow-up


Various trials have demonstrated significant increase in behavioral problems

Cognitive Development
There is a consistent association between FTT and lower cognitive development test scores in preschool and primary school children

Prognosis cont

In the 1st year of life is ominous 1/3 children with psychosocial FTT are developmentally delayed and have social and emotional problems Variable prognosis in organic FTT

Top 6 take home points


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Evaluation of Failure to Thrive involves careful H&P, observation of feeding session, and should include routine lab or other diagnostic testing Nutritional deprivation in the infant and toddler age group can have permanent effects on growth and brain development Treatment can usually occur by the primary care physician in the outpatient setting.

Top 6 take home points


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Psychosocial problems predominate as the causes of FTT in the outpatient setting (Block&Krebs 2005) Treatment goal is to increase energy intake to 1.5 times the basal requirement Earlier intervention may make it easier to break difficult behavior patterns and reduce sequelae from malnutrition

Summary: G.R.O.W.T.H.

Gather history and extensive physical Remember genetic contribution Only order basic labs in initial eval Wonder and ponder on most likely cause Track growth trends Hospitalize or hormonally treat (Logan 2005)
Failure to Thrive 36

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Bibliography
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Block RW, Krebs NF. Failure to thrive as a manifestation of child neglect. Pediatrics 2005 Nov; 116(5):1234-7. From National Guidline Clearinghouse www.guideline.gov Kirkland, RT. Failure to thrive in children under the age of two. Up to Date: http://www.utdol.com/utd/content/topic.do?topicKey=gen_pedi/2884&t ype=P&selectedTitle=6~29 version 14.2, april 2006:pgs 1-8. Krugman SD, Dubowitz H. Failure to thrive. American Family Physician, sept 1 2003. Vol 68 (5). Kane, ML. Pediatric Failure to Thrive. Clinics in Family Practice. Vol 5, #2, June 2003, pages 293-311. Agency for Healthcare Research and Quality (AHRQ); Evidence report: Criteria for Determining Disability in Infants and Children: Failure to thrive. #72, pages 1-54. http://www.ahrq.gov/clinic/ Bauchner, H. Failure to thrive, in Behrman: Nelson Textbook of Pediatrics, 17th ed, chapter 35, 36 - 2004. Rudolf M, Logan S. What is the long term outcome for children who fail to thrive? A systematic review. In Arch Dis Child 2005;90;925-931.