Failure to thrive definition and management in primary care

1. FAILURE TO THRIVE
AND OTHER
PROBLEM WITH
NUTRITION
BY: DR NURLIDA ABD RAHIM
FMS UKM YEAR 1
TELECONFERENCE SESSION 15/10/2014

2. OUTLINE OF PRESENTATION
• DEFINITION AND CLASSIFICATION
• APPROACH TO FAILURE TO THRIVE
• HISTORY
• EXAMINATION
• INVESTIGATION
• MANAGEMENT
• REVIEW PAPER
• OTHER NUTRITIONAL PROBLEM

3. WHAT IS FAILURE TO THRIVE ?
• A significant interruption in the expected rate
of growth during early childhood
• weight less than the third to fifth percentile
for age on more than one occasion or
• weight measurements that fall 2 major
percentile lines using the standard growth
charts expected of similar children of the
same sex, age and ethnicity.
REF: National Center for Health Statistics (NCHS) www.cdc.gov/nchs

4. FAILURE TO THRIVE
• Prevalence 5 to 10% of children in primary care
settings
• Up to 80 % of children with FTT present before 18
months of age.
• REF: Schwartz ID. Failure to thrive: an old nemesis in the new millennium.
Pediatr Rev. 2000;21(8):257–264.

5. NORMAL VARIANT OF GROWTH
• children of small parents who are growing to their full
genetic potential,
• large-for-gestational-age infants who regress toward
the mean (postnatal catch-down)
• children with constitutional delay in growth, or
• premature infants whose growth parameters are
normal when corrected for gestational age.
REF: Bergman P, Graham J. An approach to “failure to thrive.” Aust Fam Physician.
2005;34(9):725–729.

6. CLASSIFICATION
FTT
Organic
Medical
Non
organic
Social or environmental
*Multifactorial

7. REF: American Family Physician –Failure to Thrive: An update
http://www.aafp.org/afp/2011/0401/p829.html

8. COMMON PROBLEM IN PRIMARY CARE
• Inadequate caloric intake is the most common
etiology seen in primary care settings.
• In infants younger than eight weeks, problems
with feeding (e.g., poor sucking and
swallowing) and breastfeeding difficulties are
prominent.
• For older infants:-
• difficulty transitioning to solid foods
• insufficient breast milk or formula consumption
• excessive juice consumption and
• parental avoidance of high-calorie foods
often lead to FTT
• Family factors

9. APPROACH TO FAILURE TO THRIVE
• History: Prenatal & Perinatal
• Maternal age
• Gravidity & Parity
• Abortions / stillborn
• Pregnancy health history, including a detailed history of
weight gain, prenatal care, substance or cigarette use,
nutrition and unusual nutritional practices, general
complications, bleeding, Infections
• Labor and delivery and complications, if any
*Adapted from Medscape Article: Failure to Thrive by Andrew PS et. al. Jan 2013

10. HISTORY
• Neonatal medical history
• Gestational age determined at birth
• Intrauterine growth rate (IUGR)
• Apgar scores
• Birth weight, length, and head circumference with
percentiles
• Neonatal course and complications, including sepsis,
jaundice, feeding intolerance or feeding difficulties
• Detailed medical history of newborn period
• Completed review of newborn screens
*Adapted from Medscape Article: Failure to Thrive by Andrew PS et. al. Jan 2013

11. CHILD MEDICAL HISTORY
• Medical history
• Immunizations
• Medications and Allergies
• Food intolerance / Formula intolerance
• Weight loss
• Vomiting and/or Diarrhea
• Dysphagia
• Snoring / Sleep apnea
• Recurrent respiratory or other bacterial and viral infections
• Signs of immune deficiency
• Malabsorption symptoms and signs
• CNS abnormalities
• Growth and developmental progress(delay or regressed milestones)
*Adapted from Medscape Article: Failure to Thrive by Andrew PS et. al. Jan 2013

12. FEEDING AND NUTRITIONAL HISTORY
• Dietary details - Milk, formula, solids, vitamins, other
supplements, food allergy or intolerance
• Caregivers' knowledge - Nutrition and feeding,
dietary beliefs, religious and cultural beliefs about
food, any unusual diets that might be inappropriate
for a child, inadequate amounts or typres
• Basic food and nutritional needs - Anything that
prevents the family from getting food (eg, finances,
transportation, subsidized programs); appropriate
and safe preparation of food by the caregiver (eg,
clean water, housing or shelter, cooking facility,
refrigeration, cooking knowledge)
*Adapted from Medscape Article: Failure to Thrive by Andrew PS et. al. Jan 2013

13. FEEDING BEHAVIOUR
• Is there is any sucking, chewing or swallowing
difficulty?
• Frequency and timing of meals
• Limited food preference or negative responses to food
and feeding
• Observe breastfeeding to ensure proper technique,
latch-on and swallowing
• Quantification is easy with bottle-feeding; if
breastfeeding- for EBM and measure volume
• Food journal for three days for older children and
adolescents
• Eating habits inside and outside of the home (e.g., day
care, school)
• Eating habits of parents or siblings at the same age as
the patient.

14. PSYCHOSOCIAL HISTORY
(NON ORGANIC CAUSES)
• Finances & poverty risk factors
• Family structure and living condition
• Caregiver identity and responsibility, mental health issues including
risks for or signs of maternal postpartum depression
• Daycare use
• Beliefs about child rearing
• History of abuse or neglect
• Family substance abuse or addiction
• Violence or chaotic family structure
• Educational level of parent or caregiver
• Food subsidy (food basket, soup kitchen)
• Welfare (JKM allowance)
• Transportation problems
• Health insurance
• Family or cultural concepts on feeding and specific foods
*Adapted from Medscape Article: Failure to Thrive by Andrew PS et. al. Jan 2013

15. PHYSICAL EXAMINATION
• Detailed and careful physical examination to
detect any disease or syndrome that might affect
growth and development.
• Growth parameters (weight, length, head
circumference and BMI) should be plotted on the
appropriate growth chart.
• Multiple data points are helpful to evaluate trends
in growth. Weight should be measured with the
child unclothed.
• Some conditions, such as Down syndrome, Turner
syndrome require specific growth chart.

16. GENERAL EXAMINATION
• Vital signs - Temperature, blood pressure, pulse,
respiration, hydration status
• General - Appearance, activity, affect
• Face – Dysmorphism
• Child behaviours - Gaze avoidance, arching,
hypertonicity, refusal to attach or respond
appropriately, unusual body movements, fretfulness
• Skin and hair - Poor hair texture and amount, nails,
alopecia, hygiene, rashes, birth marks, trauma (eg,
bruises, burns, or scars as signs of physical abuse)

17. HEAD AND FACE
• Head - Size, frontal bossing, fontanelle size and
patency, dysmorphism
• Eyes - Dysmorphia, ptosis, sunset sign, palpebral
fissures, pallor, trauma, optic discs
• External ears - Size, shape, position, infection
• Middle ears - Infection, acute or chronic
• Mouth and pharynx – Palate and /or cleft
deformity, tongue, teeth, caries, glossitis, mucous
membrane hydration or lesions, thrush, bleeding,
unusual odours to the breath

18. • Chest – Chest deformity, breath sound, cardiac
examination for murmurs or cardiomegaly or
arrhythmias
• Abdomen - Protuberance, organomegaly, masses,
bowel sounds, normal umbilicus healing in infant
• Genitalia - Normal for age, malformations,
ambiguous in quality, hygiene, trauma
• Extremities - Edema; digit malformations;
examination of the nails, joints, spine, and back
• Neurologic function - Cranial nerves, reflexes
(increased or decreased), tone, infant reflexes
present or extinguished at appropriate age, gait,
suck/swallow coordination
• Muscles - Muscle development and quality and
texture of muscle mass

19. INVESTIGATION
• Investigations should be guided by the history and
examination.
• Children who are generally well – with no positive
findings - may require no immediate investigation.
• Infants who are either unwell or have significant
positive physical findings will require immediate
investigation and consideration of paediatric
referral.
• In those requiring investigation, initial screening may
include:
• FBC, ESR, RP, Ca, Mg, PO4, UFEME/C&S

20. INVESTIGATION

21. TREATMENT
• If FTT is caused by a specific medical condition –
then it should be treated accordingly. For example:
diuretics for heart failure, thyroid medication,
lactose free milk for lactose intolerance,
correctional operation for GI problem.
• Pediatric medical or surgical subspecialists should
be involved in the long-term treatment and
monitoring of organic illness if identified.

22. REF: American Family Physician –Failure to Thrive: An update
http://www.aafp.org/afp/2011/0401/p829.html

23. TREATMENT
• If a diagnosis of FTT is made and no medical conditions
are suggested on examination, appropriate guidance
for catch-up growth should be made.
• Most children require 100-120 kcal/kg/day, but this
may be increased to achieve catch-up weight gain
that is greater than normal.
• AHA estimated calories needed by children:
• 900kcal/day for a 1-year-old
• 1000kcal/day for 2-3 year old
• 1,800kcal/day for a 14–18-year-old girl
• 2,200kcal/day for a 14–18-year-old boy
• Increased physical activity will require additional
calories: by 0-200 kcal/d if moderately physically
active; and by 200–400 kcal/d if very physically active.

24. TREATMENT
• INTERDISPLINARY TEAM APPROACH- When treating
children with failure to thrive, an interdisciplinary team
approach combining pediatric, nutritional, mental
health, and social work is optimal.
• Home visits can help determine the underlying reason
for the nonorganic failure to thrive and can help
support the caregiver.
• Structured follow up plan after discharge.
• An older child with a chronic illness and failure to thrive
may benefit from referral to a psychologist.
• If neglect is suspected, child protection services should
become involved.

25. PRACTICAL DIETARY
RECOMMENDATION
• Eliminate empty calories from items such as soda or other
high sugar drinks.
• Schedule regular meals and snacks (usually 3 meals and 2
snacks per day). No grazing between meals.
• Offer solids before liquids.
• Increase protein and carbohydrates.
• Supplementation for older children may include adding
meat sauces, oil, cheese, sour cream, butter, margarine,
or peanut butter to meals.
• High-energy (approximately 1 kcal/mL) shakes, which are
available in different flavors (eg, Pedia Sure, Nutren
Junior).
• Multivitamin and mineral supplements, including iron and
zinc, are usually recommended to all undernourished
children.

26. DOES CHILD WITH FTT NEED IN-
PATIENT CARE?
• Most children with failure to thrive (FTT) can be treated
as outpatients. However, serial visits are mandatory, with
documentation of weight gain and/or daily caloric
intake.
• Who need in-patient care?
• Failure of outpatient management,
• Suspicion of abuse or neglect
• Severe psychosocial impairment of the caregiver
• Severe malnutrition as evidenced by cachexia or marasmus

27. LITERATURE REVIEW
(PEDIATRICS: 2007 JUL; 120(1):59-69)
• Early intervention and recovery among children
with failure to thrive: follow-up at age 8.
• Black MM, Dubowitz H, Krishnakumar A, Starr RH Jr.
• Department of Pediatrics, University of Maryland
School of Medicine, Baltimore, USA.

28. EARLY INTERVENTION AND RECOVERY AMONG
CHILDREN WITH FAILURE TO THRIVE:
FOLLOW-UP AT AGE 8
• Type of study: RCT
• Objectives: to examine the impact of home visiting
among infants with failure to thrive on growth,
academic/cognitive performance, and
home/classroom behavior at age 8.
• Method: Infants with failure to thrive (N = 130) or
adequate growth (N = 119) were recruited from
pediatric primary care clinics serving low-income,
urban communities.
• Eligibility criteria: included age <25 months,
gestational age >36 weeks, birth weight >2500 g,
and no significant medical conditions.

29. RANDOMIZATION
Infants with
failure to
thrive
Clinical-intervention-
plus-home-intervention
The home-visiting curriculum promoted
maternal sensitivity, parent-infant
relationships, and child development.
Clinical-care-only
groups
Infants with
adequate
growth

30. FOLLOW-UP AT AGE 8
• Follow-up visits were conducted by evaluators who
were unaware of the children's growth or
intervention history.
• At age 8, the evaluation included anthropometries,
the Wechsler Intelligence Scale for Children III, and
the Wide Range Achievement Test, Revised.
Mothers completed the Child Behavior Checklist
and teachers completed the Teacher Report Form.

31. RESULTS (RETENTION RATE :74% TO 78%)
• Analysis done by multivariate analyses of variance
• Children in the adequate-growth group were
significantly taller, heavier, and had better arithmetic
scores than the clinical-intervention-only group.
• Children in clinical-intervention-plus-home-intervention
group were also taller, heavier and had better
arithmetic scores than the clinical-intervention-only
group.
• There were no group differences in IQ, reading, or
mother-reported behavior problems.
• Children in the clinical-intervention-plus-home-
intervention group had fewer teacher-reported
internalizing problems and better work habits than the
clinical-intervention-only group.

32. CONCLUSION
• Early failure to thrive increased children's
vulnerability to short stature, poor arithmetic
performance, and poor work habits.
• Home visiting attenuated some of the negative
effects of early failure to thrive, possibly by
promoting maternal sensitivity and helping children
build strong work habits that enabled them to
benefit from school.
• Findings provide evidence for early intervention
programs for vulnerable infants.

33. OTHER PROBLEM WITH
NUTRITION

34. BURDEN OF DISEASE
• Childhood malnutrition is the underlying cause of
death in an estimated 35% of all deaths among
children under the age of five years.
• REF: Comprehensive Implementation Plan on Maternal, Infant and Young
Child Nutrition WHO 2014

35. GLOBAL TARGET NO 6:
BY 2025, REDUCE AND
MAINTAIN CHILDHOOD
WASTING
TO LESS THAN 5%.

36. WASTING REDUCTION
• improved access to high-quality foods and to health
care;
• improved nutrition and health knowledge and
practices;
• promotion of exclusive breastfeeding for the first six
months and promotion of improved complementary
feeding practices for all children aged 6–24 months;
• and improved water and sanitation systems and
hygiene practices to protect children against
communicable diseases.

37. MALNUTRITION
• Causes:
• Inadequate or unbalanced diet
• Problems with digestion or absorption
• Certain medical conditions
• Starvation is a form of malnutrition.
• Malnutrition may also developed in form
micronutrient/macronutrient deficiency.

38. MARASMUS
This 6-month-old infant was admitted with marasmus. The infant was born
to a mother who did not bond effectively because of postpartum
depression. He has evidence of severe wasting and neglectful care as
also evidenced by the diaper excoriation. Weight gain was achieved by
placement in foster home.
Sirotnak Ap et. Al. Failure to thrive. Medscape Article. 2013 Jan.

39. PROTEIN ENERGY MALNUTRITION
MARASMUS KWASHIORKOR
• Obvious loss of weight with gross
reduction in muscle mass
especially from limb girdles.
Subcutaneous fat virtually
absent.
• Thin, atrophic skin lies in folds.
• Pinched face has appearance
of old man or monkey.
• Alopecia and brittle hair.
• Sometimes, appearance of
lanugo hair.
• Usually occurs in children aged
1-2 years with changing hair
colour to red, grey or blonde.
• Moon facies, swollen abdomen
(pot belly), hepatomegaly and
pitting oedema.
• Dry, dark skin which splits where
stretched over pressure areas to
reveal pale area.

40. EXAMPLE
OF MICRO-
NUTRIENT
DEFICIENCY

41. VITAMIN DEFICIENCIES
• Beri-beri (Vitamin B1/ Thiamine deficiency)
• Vitamin B2/Riboflavin Deficiency
• Vitamin B6/ Pyrodoxine Deficiency
• Vitamin E deficiency
• Vitamin K deficiency
• Vitamin C deficiency (scurvy)
• Folic acid deficiency
• Rickets
• Pellagra

42. OBESITY
• According to WHO, the number of overweight
children under the age of five was estimated in
2010 to be more than 42 million globally.
• Obesity is caused by imbalance between energy
input and expenditure.
• Dietary habit
• Lack of exercise, sedentary lifestyle
• Sleep deprivation
• Genetic contribution
• Socio-economic status
• Physical condition (such as endocrine causes)

43. By 2025, no increase in childhood
overweight.
The target implies that the global
prevalence of 6.7% estimated for
2010 should not rise to 10.8% (in 2025)
as per current trends and that the
number of overweight children
under five years should not increase
from 42 million

44. THANK YOU

45. REFERENCES
1. Black MM, Dubowitz H, Krishnakumar A, Starr RH Jr. Early intervention and
recovery among children with failure to thrive: follow-up at age 8.
Pediatrics.2007 Jul;120(1):59-69. PubMed PMID: 17606562
2. Rabinowitz SS et. Al. Nutritional Consideration in Failure to Thrive Follow Up.
Medcape. 2014 Apr.
3. Sirotnak Ap et. Al. Failure to thrive. Medscape. 2013 Jan.
4. Cole SZ et. Al. Failure to thrive: an update. American Family
Physician. 2011 Apr 1;83(7):829-834
5. Bergman P, Graham J. An approach to “failure to thrive.” Aust Fam
Physician. 2005;34(9):725–729.
6. Rudolf MC, Logan S; What is the long term outcome for children who fail to
thrive? A systematic review. Arch Dis Child. 2005 Sep;90(9):925-31. Epub
2005 May 12
7. Shields B, Wacogne I, Wright CM; Weight faltering and failure to thrive in
infancy and early childhood. BMJ. 2012 Sep 25;345:e5931. doi:
10.1136/bmj.e5931.
8. Andrew PS et. al. Medscape Article: Failure to Thrive by Jan 2013
9. www.patient.co.uk
10. www.nlm.nih.gov/medlineplus
11. www.cdc.gov/nchs