failure to thrive

1. APPROACH TO A CHILD WITH FAILURE
TO THRIVE
- Dr. Jyoti Saroj

2. DEFINATION
 FTT results from inadequate usable calories necessary for a
child’s metabolic and growth demands.
 Weight for height ratio < 2SD (or <3 or 5 percentile) for
age and gender.

3. ETIOLOGY
 Failure of the child to ingest and utilize sufficient calories
 Malabsorption
 Increased metabolic demands
 Biological and psychosocial factors

4. INADEQUATE INTAKE
INADEQUATE FOOD ORDERED
1. Food insecurity
2. Poor knowledge of child’s need
3. Formula dilution or excessive
juice
4. Breastfeeding difficulties
5. Munchausen by proxy
6. Medical neglect
7. Food fads
NOT TAKING ENOUGH FOOD
1. Oromotor dysfunction
2. Neurologic disease
3. Developmental delay
4. Behavioural feeding problem
5. Anorexia from systemic causes
EMESIS
1. pyloric stenosis
2. GER
3. Eosinophilic esophagitis
4. Vascular rings
5. Malrotation with intermittent
volvulus
6. Raised ICP and other neurologic
disorders
7. Inborn error of metabolism
8. Rumination
9. Cyclic vomiting

5. MALABSORPTION
 Cystic fibrosis
 Celiac disease
 Hepatobiliary disease
 Food protein allergy/ insensitivity/ intolerance
 Infection (giardiasis)
 Short gut syndrome

6. INCREASED METABOLIC DEMAND
 Congenital infection (HIV, TORCHES)
 Syndromes ( Russell- Silver, Turner, Down)
 Malignancy
 Chronic disease (cardiac, pulmonary, renal)
 Metabolic disorders
 Immunodeficiency disorders
 Endocrine (diabetes mellitus, diabetes insipidus, hyperthyroidism)

7. BIOLOGICAL SPHERE
 Frequency and source of routine medical care
 Growth measurements
 Immunization status
 Medical illnesses
 Hospitalizations
 Medications
 Allergies
 Surgeries
 Injuries
 Feeding issues
 Breastfeeding
 Formula feeding
 Other intake
 Sleep schedule
 Developmental milestones
 Complementary medicines

8. PSYCHOSOCIAL SPHERES
 Provision of baby care, especially feeding
 Maternal sleep deprivation
 Postnatal depression or other mental illness
 Type and amount of social support
 Availability of respite for mother
 Financial resources,including money for baby supplies
 Enrolment in govt aid programmes
 Parental reactions to fussing/crying
 Who lives with baby
 Reactions of others in the home to the baby
 Parental employment
 Daycare/ babysitting/ caregiver

9. DD BY SYSTEM
1) PSYCHOSOCIAL/ BEHAVIORAL
 Inadequate diet because of poverty/ food insufficiency, errors in food preparation
 Poor parenting skills (lack of knowledge of sufficient diet)
 Child/ parent interaction problems (autonomy struggles, coercive feeding, maternal
depression)
 Food refusal
 Rumination
 Parental cognitive or mental health problems
 Child abuse or neglect; emotional deprivation

10. 2. NEUROLOGIC
 Cerebral palsy
 Hypothalamic and other central nervous system tumors (diencephalic
syndrome)
 Neuromuscular disorders
 Neurodegenerative disorders

11. 3. RENAL
 Recurrent UTI
 Renal tubular acidosis
 Renal failure

12. 4. ENDOCRINE
Diabetes mellitus
Diabetes insipidus
Hypothyroidism/ hyperthyroidism
Growth hormone deficiency
Adrenal insuffiency

13. 5. GENETIC/ METABOLIC/ CONGENITAL
 Sickle cell disease
 Inborn errors of metabolism (organic acidosis, hyperammonemia, storage disease)
 Fetal alcohol syndrome
 Skeletal dysplasias
 Chromosomal disorders
 Multiple congenital anomaly syndrome (VATER)

14. 6. GASTROINTESTINAL
 Pyloric stenosis
 GER
 Repair of TEF
 Malrotation
 Malabsorption syndromes
 Celiac disease
 Milk intolerance
 Pancreatic insuffiency syndromes (CF)
 Chronic cholestasis
 IBD
 Chronic congenital diarrhea states
 SBS
 Pseudoobstruction
 Hirschsprung disease
 Food allergy

15. 7. CARDIAC
 Cyanotic heart lesions
 Congestive heart failure
 Vascular rings

16. 8. PULMONARY/ RESPIRATORY
 Severe asthma
 Cystic fibrosis
 Bronchiectasis
 Chronic respiratory failure
 Bronchopulmonary dysplasia
 Adenoid/ tonsillar hypertrophy
 Obstructive sleep apnea

17. 9. MISCELLANOUS
 Collagen vascular disease
 Malignancy
 Primary immunodeficiency

18. 10. INFECTIONS
 Perinatal infection (TORCHES)
 Occult/ chronic infections
 Parasitic infestation
 Tuberculosis
 HIV

19. SIGNS AND SYMPTOMS
HISTORY/ PHYSICAL EXAMINATION
 Spitting, vomiting, food refusal
 Diarrhea, fatty stools
 Snoring, mouth breathing, enlarged tonsils
 Recurrent wheezing, pulmonary infections
 Recurrent infections
 Travel to/ from developing countries
DIAGNOSTIC CONSIDERATION
 GER, chronic tonsillitis, food allergies, eosinophilic
esophagitis
 Malabsorption, intestinal parasites, milk protein
intolerance, pancreatic insufficiency, celiac disease,
immunodeficiency, IBD
 Adenoid hypertrophy, obstructive sleep apnea
 Asthma, aspiration, food allergy, cystic fibrosis,
immunodeficiency
 HIV, congenital immunodeficiency diseases, anatomic
defects
 Parasitic or bacterial infections of GIT

20. RED FLAGS
RED FLAGS
Developmental
delay Despite adequate
caloric intake
Recurrent vomiting,
diarrheoa,
dehydration
Recurrent
mucocutaneous or
UTIdysmorphism
Murmur, edema, JVP
distension
Organomegaly or
lymphadenopathy

21. PHYSICAL EXAMINATION
 Vital signs- BP, Temp, pulse, respirations, spO2, anthropometry (growth percentiles, BMI)
 General appearance- activity, posture
 Skin- hygiene, rashes, trauma(bruises, burns, scars)
 Head- hair whorls, color, pluckability of hair, occipital alopecia, fontanel size and patency, frontal bossing, sutures,
shape, facial dysmorphisms, philtrum
 Eyes- ptosis, strabismus, fundoscopic examination where possible, palpebral fissures, conjunctival pallor, icterus,
cataracts
 Ears- external form, tympanic membranes
 Mouth, nose, throat- hydration, dental eruption and hygiene caries, glossitis, cheiliosis, gum bleeding, marked tonsillar
enlargement
 Neck- hairline, masses, lymphadenopathy
 CVS- evidence of CHF, cyanosis
 P/A- protuberance, hepatospleenomegaly, masses
 Genitalia- malformations, hygiene, trauma
 Rectum- fissures, trauma, hemorrhoids
 Extremities- edema, dysmorphism,, rachitic changes, nails and nail beds
 Neurologic- cranial nerves, reflexes, tone, retention of primitive reflexes, quality of voluntary movement

22. APPROACH

23. THANK YOU