Failure To Thrive With Notes

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  • Failure To Thrive With Notes

    1. 1. Failure to Thrive Shannon Pittman, M.D. University of Mississippi Jackson, MS
    2. 4. http://www.peacecorpsonline.org/messages/messages/2629/1008996.html
    3. 5. http://bluegoldfish.blogs.com/surface/2004/05/present_from_pr.html
    4. 6. http://www.babybabyphoto.com/family/pages/02baby_flowers.htm
    5. 7. http://www.kindersigns.com/images/corbis-black-baby.jpg
    6. 8. Objectives <ul><li>To define failure to thrive (FTT) </li></ul><ul><li>To identify major classification of FTT </li></ul><ul><li>To discuss diagnostic workup of FTT </li></ul><ul><li>To discuss treatment of FTT </li></ul>
    7. 9. Things We Will Not Cover <ul><li>Geriatric FTT </li></ul><ul><ul><li>Am Fam Physician. 2004 Jul 15;70(2):248, 257. </li></ul></ul><ul><ul><li>Rehabil Nurs. 2005 Jul-Aug;30(4):152-9 </li></ul></ul><ul><li>Adolescent FTT </li></ul>
    8. 10. Things We Will Not Cover <ul><li>Other specific causes (e.g.) </li></ul><ul><ul><li>Congenital defects </li></ul></ul><ul><ul><li>Celiac disease </li></ul></ul><ul><ul><li>HIV/AIDS </li></ul></ul><ul><ul><li>Metabolic disorders </li></ul></ul><ul><ul><li>CHF (reference for Jenny) </li></ul></ul><ul><ul><ul><li>Prog Pediatr Cardiol. 2000 Sep 1;11(3):195-202. </li></ul></ul></ul>
    9. 11. Why Do We Have to Talk About it at All? <ul><li>Personal </li></ul><ul><ul><li>Depending on current status in app. 9, 21, or 32 months you will sit for the ABFP (13%-pediatrics) </li></ul></ul><ul><ul><li>ACGME competencies / AAFP core recommendations </li></ul></ul><ul><li>Patients </li></ul><ul><ul><li>Parental concerns </li></ul></ul><ul><ul><ul><li>Doc, is my baby growing right? </li></ul></ul></ul><ul><ul><li>Cognitive development </li></ul></ul><ul><ul><ul><li>Arch Dis Child. 2005 Sep;90(9):925-31. Epub 2005 May 12. </li></ul></ul></ul><ul><ul><ul><li>J Child Psychol Psychiatry. 2004 Mar;45(3):641-54. </li></ul></ul></ul>
    10. 12. Clinical Vignette <ul><li>15 month old admitted with lethargy from dermatology office </li></ul><ul><li>Prior to admit, several days of decreased activity </li></ul><ul><li>Med hx remarkable for eczema, treated with topical steroids </li></ul>
    11. 13. Clinical Vignette <ul><li>Wgt and ht both below 5 th percentile, but had grown along the 25 th percentile until age 4mo </li></ul><ul><li>Extensive erythematous plaques on her back, diaper region, thighs, and polpliteal fossa bilaterally </li></ul>
    12. 14. Clinical Vignette <ul><li>What concerns you about this child </li></ul><ul><li>What history questions should you ask </li></ul><ul><li>What labs would you order </li></ul><ul><li>How would you manage pt’s care </li></ul>
    13. 15. Okay, Tell Me What Happens Next - <ul><li>Afternoon clinic </li></ul><ul><li>10 Patients scheduled </li></ul><ul><ul><li>Everyone of them showed up </li></ul></ul><ul><li>Your 5 th pt is new & has a typed list </li></ul><ul><li>It’s 4:00 and you are on pt 6 who happens to be a 9 mo well child </li></ul>
    14. 16. http://www.cha.state.md.us/edcp/html/immpg.html
    15. 17. We’re not alone <ul><li>In England, 54% of GP failed to diagnosis FTT </li></ul><ul><li>Residency clinic, 41% with delayed dx </li></ul><ul><li>Residency clinic, 29 dx, 100% dx incorrectly </li></ul>
    16. 18. FTT – Definition <ul><li>“Inadequate physical growth diagnosed by observation of growth over time using a standard growth chart” </li></ul>
    17. 19. Normal Growth <ul><li>Average wgt 7 lbs (3kg) </li></ul><ul><ul><li>Double by 4 months, triple by 12 </li></ul></ul><ul><li>Grow 25 cm in length during 1 st year </li></ul><ul><li>Make sure you have the right chart </li></ul><ul><ul><li>Premature </li></ul></ul><ul><ul><li>Breastfeeding </li></ul></ul><ul><ul><li>www.cdc.gov/growthcharts </li></ul></ul>
    18. 20. FTT Criteria <ul><li>Ht/Wgt less than 3 rd to 5 th percentile for age on >1 occasion </li></ul><ul><li>Ht or Wgt falling 2 major percentiles </li></ul><ul><li>Below 10 th percentile for ht/wgt </li></ul><ul><li>< 80% of ideal body wgt for age </li></ul><ul><li>Head circumference important, but not part of FTT entity </li></ul>
    19. 21. FTT <ul><li>HISTORY ! HISTORY! HISTORY! </li></ul><ul><ul><li>Prenatal </li></ul></ul><ul><ul><li>Feeding </li></ul></ul><ul><ul><ul><li># oz needed in 24 hours </li></ul></ul></ul><ul><ul><ul><ul><li>Wgt (kgs) x 5 (need 100 kcal/kg/day) </li></ul></ul></ul></ul><ul><ul><ul><li>How formula prepared </li></ul></ul></ul><ul><ul><ul><li>Good diet history (3 day journal) </li></ul></ul></ul><ul><ul><li>Bowel habits </li></ul></ul>
    20. 22. FTT <ul><li>Physical </li></ul><ul><ul><li>Gomez Criteria </li></ul></ul><ul><ul><ul><li><60 = severe; 61-75 = mod; 76-90 = mild </li></ul></ul></ul><ul><ul><li>Kwashiorkor – protein malnourishment </li></ul></ul><ul><ul><li>Marasmus – caloric deficiency </li></ul></ul><ul><ul><li>Short Stature Syndrome </li></ul></ul><ul><ul><li>Constitutional Delay </li></ul></ul>
    21. 23. FTT - Classification <ul><li>Organic FTT </li></ul><ul><ul><li>Pre/postnatal </li></ul></ul><ul><li>Nonorganic FTT (NOFT) </li></ul><ul><ul><li>Pre/postnatal </li></ul></ul><ul><li>Mixed (25%) </li></ul>
    22. 24. FTT - Classification <ul><li>Organic FTT </li></ul><ul><ul><li>Prenatal Causes </li></ul></ul><ul><ul><ul><li>Prematurity w/complications </li></ul></ul></ul><ul><ul><ul><li>Toxic exposure </li></ul></ul></ul><ul><ul><li>Postnatal </li></ul></ul><ul><ul><ul><li>Inadequate intake </li></ul></ul></ul><ul><ul><ul><ul><li>Lack of appetite </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Inability to suck/swallow </li></ul></ul></ul></ul>
    23. 25. FTT - Classification <ul><li>Organic, postnatal cont. </li></ul><ul><ul><ul><li>Poor absorption and/or use of nutrients </li></ul></ul></ul><ul><ul><ul><ul><li>GI disorder (celiac, CF) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Inborn errors of metabolism </li></ul></ul></ul></ul><ul><ul><ul><li>Increased metabolic demand </li></ul></ul></ul><ul><ul><ul><ul><li>Hyperthyroidism </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Chronic Disease </li></ul></ul></ul></ul>
    24. 26. FTT - Classification <ul><li>Nonorganic </li></ul><ul><ul><li>Prenatal </li></ul></ul><ul><ul><ul><li>Malnourished mother </li></ul></ul></ul><ul><ul><ul><li>? Lack of prenatal bonding </li></ul></ul></ul><ul><ul><li>Postnatal </li></ul></ul><ul><ul><ul><li>Poor feeding skills/disorder </li></ul></ul></ul><ul><ul><ul><li>Dysfunctional family </li></ul></ul></ul><ul><ul><ul><li>Difficult parent-child interactions </li></ul></ul></ul><ul><ul><ul><li>Difficult Child </li></ul></ul></ul><ul><ul><ul><li>Abuse/Neglect </li></ul></ul></ul>
    25. 28. Recap - Classification Failure to Thrive Organic Nonorganic Prenatal Postnatal Toxic Exposure Inborn errors Prenatal Postnatal Malnourished mother Abuse/Neglect
    26. 29. FTT - Workup <ul><li>+/- Basic screening labs </li></ul><ul><ul><li>CBC, Chemistry, & UA </li></ul></ul><ul><li>Specific test directed by history </li></ul><ul><ul><li>HIV, ESR, TSH, Sweat chloride test, serum IGF-I, serum IgA/IgG antigliadin antibiodies </li></ul></ul><ul><li>X-rays for bone age </li></ul>
    27. 30. FTT – Treatment <ul><li>High calorie diet for catch up growth </li></ul><ul><ul><li>150% of recommended daily caloric intake based on expected wgt </li></ul></ul><ul><li>+/- Feeding behavior modification </li></ul><ul><li>Psychosocial involvement/ intervention </li></ul><ul><li>Close follow up </li></ul><ul><ul><li>Physical and cognitive delays </li></ul></ul><ul><li>Hospitalization when necessary </li></ul>
    28. 31. Clinical Vignette <ul><li>15 month old admitted with lethargy from dermatology office </li></ul><ul><li>Prior to admit, several days of decreased activity </li></ul><ul><li>Med hx remarkable for eczema, treated with topical steroids </li></ul>
    29. 32. Clinical Vignette <ul><li>Wgt and ht both below 5 th percentile, but had grown along the 25 th percentile until age 4mo </li></ul><ul><li>Extensive erythematous plaques on her back, diaper region, thighs, and polpliteal fossa bilaterally </li></ul>
    30. 33. Clinical Vignette <ul><li>What concerns you about this child </li></ul><ul><li>What history questions should you ask </li></ul><ul><li>What labs would you order </li></ul><ul><li>How would you manage pt’s care </li></ul>
    31. 34. Summary: G.R.O.W.T.H. <ul><li>G ather history and extensive physical </li></ul><ul><li>R emember genetic contribution </li></ul><ul><li>O nly order basic labs in initial eval </li></ul><ul><li>W onder about zebras </li></ul><ul><li>T rack growth trends </li></ul><ul><li>H ospitalize or hormonally treat </li></ul>
    32. 35. Take Home <ul><li>The keys to diagnosing FTT is finding the time to accurately measure and plot wgt/ht and then access the trend </li></ul>
    33. 36. http://www.cha.state.md.us/edcp/html/immpg.html <ul><li>Afternoon clinic </li></ul><ul><li>10 Patients scheduled </li></ul><ul><ul><li>Everyone of them showed up </li></ul></ul><ul><li>Your 5th pt is new & has a typed list </li></ul><ul><li>It’s 4:00 and you are on pt 6 who happens to be a 9 mo well child </li></ul>
    34. 37. Any Questions? www.child.com/.../ baby_babble.jsp
    35. 38. References <ul><li>Listernick, R. (2004). Accurate feeding history key to failure to thrive. Pediatr Ann , 33:3, 161-9. </li></ul><ul><li>Burgos, R., Jutte, D. (2000). Resident’s column: “doctor, is my child growing ok?”. Pediatr Ann , 29:9, 585-7. </li></ul><ul><li>Krugman, S., Dubowitz,H. (2003). Failure to thrive. American Fam Phy, 68:5, 879-84. </li></ul><ul><li>Schwartz, R., Abegglen, J. (1996). Failure to thrive: an ambulatory approach. Nurse Pract, 21:5, 19-31. </li></ul><ul><li>Careaga, M., Kernder, J. (200). A gastroenterologist’s approach to failure to thrive. Pediatr Ann . 29:9, 558-67. </li></ul><ul><li>Bassali, R., Benjamin, J. (2004, August 11). Failure to Thrive. eMedicine. Retrieved September 17, 2005, from http:///www.emedicine.com/ped/topic738.htm. </li></ul>
    36. 39. Thanks for Your Attention! www.jade-designs.org/ tubetotin/jababybottom.gif

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