2-Failure-to-Thrive (1).ppt
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This document discusses failure to thrive in children. It begins by defining failure to thrive as inadequate nutrition leading to abnormal growth. Growth charts are then reviewed as tools to identify failure to thrive. The causes of failure to thrive are categorized as inadequate calories, inability to utilize calories, and increased caloric needs. Child abuse, including neglect, medical child abuse, and physical/sexual abuse, are also discussed as potential causes. The evaluation, treatment, and multidisciplinary management of failure to thrive are outlined.
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2-Failure-to-Thrive (1).ppt
- 1. Failure to Thrive Premi Suresh, MD, FAAP
- 2. Learning Objectives The participant will be able to… • Review use of growth charts. • Know how failure to thrive is identified. • Be familiar with the three broad categories of causes of Failure to Thrive (FTT). • List ways in which FTT could result from abuse and neglect. • Learn strategies for management of children with FTT.
- 3. Background • Failure to Thrive (FTT) is a common problem in pediatric populations • Accounts for 1-5% of referrals to children’s hospitals/tertiary care centers • May be under diagnosed • 20-50% may not be picked up by physician
- 4. Background • In low-income countries, poverty is the most common cause of Failure to Thrive; however, medical providers, social services and law enforcement must learn about the entire family to see if this child – for any reason – was not given food that was given to others in the family.
- 6. Growth Charts • U.S. Centers for Disease Control (CDC) • Growth reference • How children grow in the U.S. • World Health Organization (WHO) • Growth standard • How children should grow in ideal conditions • Recommended for use in children under 2
- 7. CDC or WHO? • WHO growth chart may be better for children under 2 years old • WHO more appropriate for exclusively breastfed infant • WHO may take into account cultural differences • Still no consensus among providers
- 8. CDC chart
- 9. WHO Chart
- 11. Failure to Thrive • Not a diagnosis - a description • Inadequate nutrition to sustain normal growth and development • Significantly prolonged cessation of appropriate weight gain compared with recognized norms for age/gender after having achieved stable pattern
- 12. Criteria • Weight curve crossing 2 major percentile lines on growth chart after achieving stable pattern • Weight for age or weight for height more than 2 standard deviations below mean for gender/age
- 16. Thomas
- 17. Midparental height Boys: Girls: Father’s ht (in) + Mother’s ht (in)+5 2 Father’s ht (in) + Mother’s ht (in) -5 2
- 19. Organic vs. Non-Organic • Not a helpful distinction • Both overlap • Too simplistic • Malnutrition causes growth failure
- 20. Causes of FTT • Inadequate calories • Inability to utilize calories • Increased caloric needs More than one of these causes can overlap!!
- 22. Inadequate Calories • Lack of knowledge • Behavior • Psychosocial • Anatomic
- 23. Inadequate Calories Lack of knowledge • Diet (low calorie, excess juice, fads) • Formula mixing Behavior issues • Grazing • Behavior problems • Oral aversion • Food phobia
- 24. Feeding Infants • Breast milk or formula in first year of life • No water needed in first 4-6 months • Offer water in sippy cup • Solids introduced at 4-6 months • Juice not necessary! • Should not exceed 4-6 ounces/day • Transition to WHOLE milk at 1 yr of age
- 25. Growth in infancy AGE Weight gain/day (grams) Weight gain/mo Growth in length (cm/mo) Growth in Head Circ (cm/mo) RDA (kcal/kg/day) 0-3 mos 30 2 lb 3.5 2.0 115 3-6 mos 20 1.25 lb 2.0 1.0 110 6-9 mos 15 1lb 1.5 0.5 100 9-12 mos 12 13 oz 1.2 0.5 100
- 26. Caloric intake • Breastmilk and Standard Infant formula have 20 calories per oz • Formula should be mixed 1 scoop to 2 oz water • There are special formulas with higher calories per oz
- 27. Toddlers • Growth less rapid • Can become picky • Food “jags” • Bottle should be discontinued • Self feeding encouraged • Avoid battles over food
- 28. Stop Grazing • Offer 3 meals and 3 snacks per day • Separate meals and snacks by 2-2.5 hours • Only water between meals and snacks • Meals and snacks should be offered at a table or highchair and should last 20-25 minutes • Solid foods should be offered before liquids
- 29. Inadequate Calories Psychosocial • Poverty/financial • Formula mixing • Abuse/neglect/IPV • Parental mental health issues • Parental eating disorders
- 30. Inadequate Calories Anatomic •Congenital anomalies •Oromotor dysfunction •Dental caries •Gastroesophageal reflux •Obstruction (i.e. pyloric stenosis)
- 31. Inability to Utilize Calories Malabsorption • Milk protein allergy • Cystic fibrosis • Pancreatic insufficiency • Biliary atresia • Short gut or necrotizing enterocolitis • Inflammatory bowel disease • Chronic diarrhea • Disaccharidase deficiency Improper utilization • Inborn errors of metabolism • Storage disorders • Growth hormone deficiency
- 32. Increased Caloric Needs • Prematurity • Recurrent infection • Cardiac disorders • Congenital heart disease, heart failure • Pulmonary disorders • Chronic lung disease, poorly controlled asthma • Cancer • Kidney problems • Renal tubular acidosis, chronic renal failure • Chronic liver disease • Obstructive sleep apnea • Chronic infection (HIV, Tuberculosis)
- 33. Case Scenario • Pt is a 2 yr 5 mo male brought to the Hospital after being found unresponsive at home. Doctors found the patient’s abdomen was abnormally large, his legs were extremely swollen and face and arms appeared malnourished and gaunt. Doctors report that patient has been found to have a large abdominal tumor. Per mother’s report patient has been “unwell” for several months.
- 35. Findings • Tumor: Metastatic Wilms (weighed 5 kg) • Albumin <1 • Prealbumin 9 (nl 19-38) • 3>5.4<53 • Head CT- brain atrophy • Bony demineralization
- 37. Is this patient failing to thrive?
- 38. Causes of FTT • Inadequate calories • Inability to utilize calories • Increased caloric needs More than one of these causes can overlap!!
- 40. Child abuse causing FTT • Neglect • Pediatric Condition Falsification • Other- effects of physical abuse, sexual abuse
- 41. Case Scenario Patient is a 2 month old male. Mother took him to the primary doctor for immunizations. Doctor became concerned because the baby was very small and considered to be failure to thrive. Baby’s birth weight was 6 lbs, 6oz ( 3.3 Kg). At 1 month of age baby weighed 7 lbs, 6 oz. At today’s 2 month visit, baby weighed 7 lbs 5 oz. Mother told doctors that she gives the baby 32 oz of formula per day which the doctors said was an appropriate amount. Nurses report that mother is not engaged in the child’s care and sleeps most of the time. Nursing staff had to wake mother to participate in diaper changes and feedings.
- 42. Child Abuse Causing FTT • Neglect • Food withholding • Caregiver mental health issues • Caregiver substance abuse • Poor attachment • Domestic violence • Lack of follow through/medical neglect
- 43. Case Scenario
- 44. Case Scenario
- 45. Case Scenario
- 46. Case Scenario Patient is a 12 month old female with failure to thrive. Hospital physicians are concerned because child appears to be normal, eat well and gain weight while in the hospital. However, child’s primary physician is worried that the child has an underlying medical condition. She frequently has diarrhea and has days where she vomits with every meal. The child has had numerous medical lab tests and imaging studies that have not determined what is causing her vomiting and diarrhea. Mother brings the child to all appointments and seems very appropriate and engaged in child’s care.
- 47. Child Abuse Causing FTT • Fabricated or Induced Illness (Medical Child Abuse or Pediatric Condition Falsification • Induced FTT • Giving the child laxatives, ipecac, etc • Fabricated symptoms • Reporting symptoms that child not experiencing • Leads to further workup, tests
- 48. Child Abuse Causing FTT Pediatric condition falsification (PCF) • Caregivers typically present well • May be extremely attentive • “Model” caregivers • Will be opposite of caregivers who are neglecting the child
- 49. Child Abuse Causing FTT • Physical/Sexual abuse • Could cause behavioral symptoms that lead to failure to thrive • Food refusal • Vomiting • Can co-exist with neglect
- 50. Evaluation & Management • History • Physical exam • Laboratory testing • Treatment
- 51. History • Prenatal/Birth • Medical history • Surgical history • Medications • Allergies • Symptoms • Development • Family history • Social history • Diet history • Three day food diary
- 52. Physical Exam • Weight, height, head circumference • Same scale best • Standing height after 2 years of age • Complete physical exam • Observe parent-child interaction • Observe feeding • Signs of neglect • Hygiene, teeth, diaper area
- 53. Laboratory Studies • Focused lab evaluation • Common labs include: • Complete blood count • Electrolytes • Urinalysis • Thyroid studies • Sweat test (cystic fibrosis) • Majority of time, labs unhelpful
- 54. Treatment: Aimed at Cause of FTT • Dietary changes • Increase calories • Behavioral changes • Scheduled, structured mealtimes • Home visitation • Document weight, check in with family, observe home dynamics • Hospitalization • Severe cases, suspected abuse, failure of outpatient treatment
- 55. Multidisciplinary Teams • Best way to address FTT • Medical Provider • Dietician • Social Worker • Visiting nurse • Occupational therapy • Developmental specialist
- 56. Outcomes • Depends on case • Prognosis on growth typically good; however 25- 60% may remain small • Cognitive deficits, learning disability, behavioral problems seen in follow up • Hard to tease out affects of FTT because of co- morbidities
- 57. References • Kleinman R, Pediatric Nutrition Handbook 6th edition. American Academy of Pediatrics; 2009. • Reece R, Christian C, eds. Child Abuse, Medical Diagnosis and Management. 3rd edition. American Academy of Pediatrics; 2009. • Block, BW, Krebs, NF, et al. Failure to Thrive as a Manifestation of Child Neglect. Pediatrics 2005; 116:1234-1237. • Krugman, SD, Dubowitz, H. Failure to Thrive. Amer Fam Phys 2003; 68(5): 879-884 • Bools,C. Fabricated or Induced Illness in a Child by a Carer: A Reader. Radcliffe Publishing, Oxford 2007
Editor's Notes
- Accounts for 1-5% of referrals to childen’s hospitals in the US. Many cases don’t even make it to the pediatrician, therefore it can be underdiagnosed.
- Accounts for 1-5% of referrals to childen’s hospitals in the US. Many cases don’t even make it to the pediatrician, therefore it can be underdiagnosed.
- Growth charts are an important tool to use when assessing for failure to thrive. They can help determine what the “pattern” of growth has been like. Looking at only one point on a growth chart may not be very helpful as it is more important to see what the trend has been like, rather than one point in time. There are two major growth charts that are typically used. The CDC growth chart has been more commonly used in pediatrician’s offices however it really is a reflection of how children grow in the US. The WHO growth chart takes into account children from various countries around the world who are breastfed under ideal conditions (not war-time, famine, countries w/ civil unrest, etc)
- Generally the WHO growth chart is more appropriate for infants under 2 who are breast fed.
- This is an example of an 18 month old child who was below the 5% on the CDC curve.
- When the same child is plotted on the WHO curve, they are at the 10%ile! This demonstrates the difference between the curves. Again, this points out that a single point on a curve may be less important than looking at the overall trend in growth.
- Failure to thrive really is not a diagnosis- it is just a description of how the child is doing. A child who is failing to thrive is getting inadequate nutrition to sustain normal growth and development.
- There are no hard and fast ways to diagnose FTT, but these are 2 criteria that are suggested in considering the possibility of FTT. However, as you’ll see in the following examples, just because a child may meet one of these criteria, does not necessarily mean they are failing to thrive.
- What do you notice about this curve? The child is decreasing in weight and height percentiles over time. However, for the last 1 year (3 points) the child remains stable on the 10%ile for weight. Sometimes children between 12 mos to 2 years have a period of growth decline where they trend downward to find “their curve”. Sometimes children are born on the 75%ile but don’t really belong there based on genetics and other factors, they may trend downward to find their own curve. The reassuring thing is the child is not losing weight nor staying the same weight. Also, she is stable now on the 10% and height is stable at 25%ile.
- What do you notice in this growth chart? The points are all very close to or below the 5%ile. However, the child has been following a predictable pattern of growth since birth. He never loses weight or stays the same weight. He is just a smaller child and has been this way since birth.
- Making sense of the growth chart is easier when you take into account the weight for height. If the weight for height is low, this means that the child’s weight is not appropriate for their height. This is more concerning than simply if their weight for age is low.
- This is the weight for height for the child Thomas whose growth chart we looked at before. Remember both his weight and height were low but his weight for height is NORMAL (10%ile). This shows Thomas weighs an appropriate amount for how tall he is.
- The midparental height equation can be used to estimate what the child’s expected height might be.
- After seeing two growth charts where children met one of the criteria to consider for FTT but would be considered normal, you may be wondering what an abnormal growth chart would be like. Here’s an example of a clearly abnormal chart. There is little to no weight gain between 15 mos and 22 mos. This is highly concerning. Also, the child’s height is starting to be affected. This blunting of the height can occur after periods of malnourishment. Often times linear growth is spared initially, but then drops off as months go by.
- Describing FTT as organic or non-organic is not helpful. This is an old distinction that was used meaning that the cause of FTT was EITHER a medical problem OR a social problem. We know now that FTT is often caused by many factors that may overlap.
- A better way to look at the causes of FTT are to think of them as 3 separate categories.
- Here is a diagram of normal growth. Food goes into the baby, those calories are metabolized, some of which are used for growth. By products of metabolism are excreted as waste.
- In the case of inadequate calories, the amount of food/calories that are getting in are reduced. There can be a number of reasons why.
- These are some routine guidelines parents should follow for infants.
- This chart shows average weight gain in grams per day and lbs per month for different ages. It also shows about how many calories per kilo per day children should be getting.
- Toddlers gain less weight per day than infants. They will have ups and downs with their food consumption and should not be force fed. This can lead to oral aversion and severe behavioral problems associated with food. They should be provided food at meal and snack times and if they choose not to eat, the food can be put away until the next scheduled meal or snack time.
- Meals and snacks should be spaced out by 2-2.5 hours and no food should be offered in between. This prevents children from blunting their appetite and should promote a bigger appetite at meals and snack times.
- Another cause of inadequate calories can be various psychosocial issues. Child abuse would fall in this category. The child could be neglected and therefore not get the appropriate amount of calories. Or child abuse where the caregiver is not giving the child food (ie factitious disorder) and then bringing the child to the doctor with FTT.
- There are anatomic causes for inadequate calories. Example- cleft palate
- The second major cause of FTT is inability to utilize calories. Often this is the result of malabsorption. This will cause symptoms of diarrhea.
- The third major category of cause of FTT is increased caloric needs. Children with chronic illness may have a higher metabolic demand and therefore need more calories than the average child. So while they may be taking in appropriate amount of calories for a child their age, it may not be enough.
- This is a scenario that involves inadequate caloric intake due to child abuse (in form of medical and physical neglect) AND a cause of increased caloric needs (Wilm’s tumor). Have the participants read the study and offer their impressions as to what might be going on here.
- If the participants plot the child’s height and weight they will see the weight on the curve but the height is significantly below the curve. This makes the weight for height abnormally HIGH! Hmmm???
- It turns out they find a 5 kg tumor tumor in the patient’s abdomen, his labs are abnormal, his CT shows atrophy and bones are demineralized.
- This is the patient.
- When you take into account the weight of the tumor which was 10 lbs! this drops the weight and thus makes the weight for height normal b/c the height has been blunted and is abnormally low. Remember that chronic malnutrition can cause the height to be affected.
- A better way to look at the causes of FTT are to think of them as 3 separate categories.
- There are three major ways that child abuse can cause FTT. Neglect – slide follows. Pediatric Condition falsification may be called by other names (medical child abuse, fabricated or induced illness). Although Munchausen Syndrome by Proxy is a familiar term, it has largely been replaced when describing the harm experienced by the child. The other category refers to sometimes when children have severe emotional or behavioral responses to abuse (PA or SA) and may vomit or induce vomiting or have lack of appetite etc.
- This is a scenario where mother had little bond with baby. There were concerns about substance abuse or mental health problem. Mother reported she was feeding baby but when baby was hospitalized, he gained weight without a problem, proving that he was not getting adequate calories when he was in the home.
- Photos demonstrate loose skin folds, thin appearance
- Thin, bones apparent, severe diaper rash- raising question of whether he was left in wet diapers for long periods of time.
- Here is his growth chart. With interventions from CPS and support in home, he did well and caught back up with his weight.
- This is a scenario that suggests MSBP or pediatric condition falsification.
- Formerly known as Munchhausen Syndrome by Proxy.
- I have seen several children who still do not gain weight once removed and in foster care. At times, the children still have visitation with bio parents and this visitation can cause severe emotional disturbance or reactions where the child vomits and/or refuses to eat. In one case, we petitioned the judge to suspend visitation and during that time, the child gained weight and did not have these emotional outbursts.
- Need very complete history
- Need to do physical exam
- Many times labs are unnecessary and/or unhelpful. Can do focused lab work based on symptoms/history
- Treatment needs to be aimed at cause of FTT. There may be a variety of needs identified, and those needs should be addressed. (ie teaching caregiver specifically how to mix formula, feed infant, care for the child etc). Also, developmental needs should be addressed as well.
- Helpful to have MDT
- Children with FTT may be developmentally delayed. It can be hard to tease out what delays are from the nutritional issues and what are from neglect and other issues going on with the child.