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Objectives
•   To define failure to thrive (FTT)
•   To identify major classification of FTT
•   To discuss diagnostic workup of FTT
•    To discuss treatment of FTT
Failure to Thrive
• A descriptive term, not a specific diagnosis
• Failure to thrive (FTT) is the result of
  inadequate usable calories necessary for a
  child's metabolic and growth demands, and it
  manifests as physical growth that is
  significantly less than that of peers.
DEFINITIONS
• The best definition for FTT is the one that
  refers to it as inadequate physical growth
  diagnosed by observation of growth over time
  using a standard growth chart, such as the
  National Center for Health Statistics (NCHS)
  growth chart.
DEFINITION
• Weight below the third percentile for age on
  the growth chart or more than two standard
  deviations below the mean for children of the
  same age and sex
• Weight-for age(weight-for-height) Z-score less
  than minus two.
• Downward change in growth that has crossed
  two major growth percentiles in a short time.
PITFALLS OF DEFINITIONS
• Using the third percentile for defining FTT
• In the first 2 years of life, the child’s weight
  changes to follow the genetic predisposition of
  the parent’s height and weight.
• During this time of transition,children with
  familial short stature may cross percentiles
  downward and still be considered normal.
Normal Variants
EPIDEMIOLOGY
• FTT affects 5–10% of young children and
  approximately 3–5% of children admitted into
   teaching hospitals
• Under-feeding is the single commonest cause
  of FTT that results from parental poverty
  and/or ignorance
• Ninety-five percent of cases of FTT are due to
  inadequate food offered or taken.
CLASSIFICATION OF FTT
• Traditionally, causes of FTT have been
  classified as nonorganic and organic.
• Based on pathophysiology,
(i) inadequate caloric intake;
(ii) inadequate absorption;
(iii) increased caloric requirement, and;
(iv) defective utilization of calories.
NON-ORGANIC (PSYCHOSOCIAL) FAILURE TO THRIVE

• It is due to poverty, psychosocial problems in the
  family, maternal deprivation, lack of knowledge
  and skill in infant nutrition among the caregivers.
• Other risk factors include substance abuse by
  parents,single parenthood, general immaturity
  of one or both parents, economic stress and
  strain, temporary stresses such as family
  tragedies or marital disharmony.
ORGANIC FAILURE TO THRIVE
•   Infections (HIV, Tuberculosis, Parasitosis)
•   Gastrointestinal (Chronic diarrhea, GERD)
•   Neurological (Cerebral palsy, MR)
•    Urinary tract infection is a major preventable
    and treatable cause of FTT and all patients
    presenting with FTT should be evaluated in
    that regard.
CAUSES OF FAILURE TO THRIVE
• PRENATAL               • POSTNATAL
 Prematurity             (i) inadequate caloric
 exposure in utero to     intake;
  toxic agents            (ii) inadequate
 intrauterine growth      absorption;
  restriction from any    (iii) increased caloric
  cause                    requirement, and;
                          (iv) defective utilization
                           of calories
EVALUATION OF A CHILD WITH FTT
HISTORY
                                LABOUR, DELIVERY, AND NEONATAL
PRENATAL                        EVENTS
• General obstetrical history   • Neonatal asphyxia
• Recurrent miscarriages        • Prematurity
• Use of medications, drugs,    • Birth weight
  or cigarettes                 • Congenital malformations
                                  or infections
                                • Maternal bonding at birth
                                • Breastfeeding support
                                • Feeding difficulties during
                                  neonatal period
Medical history of child            Social history
•   Regular physician               • Age and occupation of parents
•   Immunizations                   • Who feeds the child?
•   Development                     • Life stressors (loss of job,
                                      divorce, death in family)
•   Medical or surgical illnesses
                                    • Availability of social and
•   Frequent infections               economic support
                                    • Perception of growth failure as
                                      a problem
                                    • History of violence or abuse of
                                      care-giver
Nutritional history
•   Details of breast feeding
•   Vitamin and mineral supplements
•   Solid foods
•   food likes and dislikes, allergies or
    idiosyncracies.
Review of systems/clues to organic
                 disease
•   Anorexia
•   Change in mental status
•   Dysphagia
•   Stooling pattern and consistency
•   Vomiting or gastroesophageal reflux
•   Recurrent fever
•   Dysuria, urinary frequency
•   Activity level, ability to keep up with peers
EXAMINATION
•   Clues for a Psychosocial etiology
•   Identification of dysmorphic features
•   Detection of an underlying disease
•   Signs of possible child abuse
•   Severity of Malnutrition
POSSIBLE NON-ORGANIC FTT
• Evidence of neglected hygiene
• Diaper rash, unwashed skin
• Overgrown and dirty fingernails or dirty clothing
• Avoidance of eye contact, lack of facial expression
• Absence of cuddling response
• hypotonia and assumption of infantile posture
  with clenched fists
• There may be marked preoccupation with thumb
  sucking
Assessment of degree of FTT
Some more clues…
• If weight, height and head circumference are all
  less than what is expected for age, this may
  suggest an insult during intrauterine life or
  genetic/chromosomal factors.
• If weight and height are delayed with a normal
  head circumference, endocrinopathies or
  constitutional growth retardation should be
  suspected.
• When only weight gain is delayed, this usually
  reflects recent energy deprivation.
Further evaluation
•   Use of appropriate growth charts
•   Developmental assessment
•   Parent-child interaction
•   Observation of feeding
LABORATORY EVALUATION
• Initial screening investigations and further
  investigations as suggested by history and
  physical examination
MANAGEMENT OF THE CHILD
        WITH FAILURE TO THRIVE
•   The child’s diet and eating pattern
•   The child’s developmental stimulation
•   Improvement in care-giver skills
•   Presence of any underlying disease
•   Regular and effective follow up
DIET AND EATING PATTERN
• Feeding interval should not be greater than four
  hours and the maximum time allowed for
  suckling should be 20 minutes.
• Eliminating distractive events
• Avoiding fruit juices
• For older infants and young children meals should
  last for about 30 minutes, solid foods should be
  offered before liquids, environmental distraction
  should be minimized not be force-fed.
CATCH-UP GROWTH
• Gaining weight at a rate greater than 50th
  percentile for the age.
• 1.5 to 2 times the expected calorie intake for
  the age
• Energy-dense foods
Monitoring nutritional therapy
• The first priority is to achieve an ideal weight-
  for-age.
• The second goal is to attain a catch-up in
  length expected for the child’s age.
• Effectiveness of therapy is monitored by gain
  in weight
• Establishes the diagnosis of psychosocial FTT.
Weight Gain
DEVELOPMENTAL
              STIMULATION
• Intensive environmental stimulation
• Foster homes
OTHER ASPECTS
• Improvement in care-giver skills
• Presence of any underlying disease
• Regular and effective follow up
COMPLICATIONS
• Malnutrition-infection cycle
• Cognitive disability
• Re-feeding syndrome
Re-feeding Syndrome
• fluid retention, hypophosphatemia,
  hypomagnesemia and hypokalemia.
• calories can safely be started at 20% above
  the child’s recent intake.
• Increased by 10-20% per day
• If no estimate of caloric intake is available, 50
  to 75% of the normal energy requirement is
  safe
PREVENTION OF FAILURE TO THRIVE
• Promotion of exclusive breast feeding for early
  infancy
• Community effort
• Encouraging parenting education courses
• Early detection of FTT and intervention
• Prevention of low birthweight
• Neonatal screening for treatable metabolic
  disorders
SIMPLIFIED APPROACH to FTT
Approach to a child with failure to thrive
Approach to a child with failure to thrive

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Approach to a child with failure to thrive

  • 1.
  • 2. Objectives • To define failure to thrive (FTT) • To identify major classification of FTT • To discuss diagnostic workup of FTT • To discuss treatment of FTT
  • 3. Failure to Thrive • A descriptive term, not a specific diagnosis • Failure to thrive (FTT) is the result of inadequate usable calories necessary for a child's metabolic and growth demands, and it manifests as physical growth that is significantly less than that of peers.
  • 4. DEFINITIONS • The best definition for FTT is the one that refers to it as inadequate physical growth diagnosed by observation of growth over time using a standard growth chart, such as the National Center for Health Statistics (NCHS) growth chart.
  • 5. DEFINITION • Weight below the third percentile for age on the growth chart or more than two standard deviations below the mean for children of the same age and sex • Weight-for age(weight-for-height) Z-score less than minus two. • Downward change in growth that has crossed two major growth percentiles in a short time.
  • 6. PITFALLS OF DEFINITIONS • Using the third percentile for defining FTT • In the first 2 years of life, the child’s weight changes to follow the genetic predisposition of the parent’s height and weight. • During this time of transition,children with familial short stature may cross percentiles downward and still be considered normal.
  • 8. EPIDEMIOLOGY • FTT affects 5–10% of young children and approximately 3–5% of children admitted into teaching hospitals • Under-feeding is the single commonest cause of FTT that results from parental poverty and/or ignorance • Ninety-five percent of cases of FTT are due to inadequate food offered or taken.
  • 9. CLASSIFICATION OF FTT • Traditionally, causes of FTT have been classified as nonorganic and organic. • Based on pathophysiology, (i) inadequate caloric intake; (ii) inadequate absorption; (iii) increased caloric requirement, and; (iv) defective utilization of calories.
  • 10. NON-ORGANIC (PSYCHOSOCIAL) FAILURE TO THRIVE • It is due to poverty, psychosocial problems in the family, maternal deprivation, lack of knowledge and skill in infant nutrition among the caregivers. • Other risk factors include substance abuse by parents,single parenthood, general immaturity of one or both parents, economic stress and strain, temporary stresses such as family tragedies or marital disharmony.
  • 11. ORGANIC FAILURE TO THRIVE • Infections (HIV, Tuberculosis, Parasitosis) • Gastrointestinal (Chronic diarrhea, GERD) • Neurological (Cerebral palsy, MR) • Urinary tract infection is a major preventable and treatable cause of FTT and all patients presenting with FTT should be evaluated in that regard.
  • 12. CAUSES OF FAILURE TO THRIVE • PRENATAL • POSTNATAL  Prematurity  (i) inadequate caloric  exposure in utero to intake; toxic agents  (ii) inadequate  intrauterine growth absorption; restriction from any  (iii) increased caloric cause requirement, and;  (iv) defective utilization of calories
  • 13. EVALUATION OF A CHILD WITH FTT
  • 14. HISTORY LABOUR, DELIVERY, AND NEONATAL PRENATAL EVENTS • General obstetrical history • Neonatal asphyxia • Recurrent miscarriages • Prematurity • Use of medications, drugs, • Birth weight or cigarettes • Congenital malformations or infections • Maternal bonding at birth • Breastfeeding support • Feeding difficulties during neonatal period
  • 15. Medical history of child Social history • Regular physician • Age and occupation of parents • Immunizations • Who feeds the child? • Development • Life stressors (loss of job, divorce, death in family) • Medical or surgical illnesses • Availability of social and • Frequent infections economic support • Perception of growth failure as a problem • History of violence or abuse of care-giver
  • 16. Nutritional history • Details of breast feeding • Vitamin and mineral supplements • Solid foods • food likes and dislikes, allergies or idiosyncracies.
  • 17. Review of systems/clues to organic disease • Anorexia • Change in mental status • Dysphagia • Stooling pattern and consistency • Vomiting or gastroesophageal reflux • Recurrent fever • Dysuria, urinary frequency • Activity level, ability to keep up with peers
  • 18. EXAMINATION • Clues for a Psychosocial etiology • Identification of dysmorphic features • Detection of an underlying disease • Signs of possible child abuse • Severity of Malnutrition
  • 19. POSSIBLE NON-ORGANIC FTT • Evidence of neglected hygiene • Diaper rash, unwashed skin • Overgrown and dirty fingernails or dirty clothing • Avoidance of eye contact, lack of facial expression • Absence of cuddling response • hypotonia and assumption of infantile posture with clenched fists • There may be marked preoccupation with thumb sucking
  • 21. Some more clues… • If weight, height and head circumference are all less than what is expected for age, this may suggest an insult during intrauterine life or genetic/chromosomal factors. • If weight and height are delayed with a normal head circumference, endocrinopathies or constitutional growth retardation should be suspected. • When only weight gain is delayed, this usually reflects recent energy deprivation.
  • 22. Further evaluation • Use of appropriate growth charts • Developmental assessment • Parent-child interaction • Observation of feeding
  • 23. LABORATORY EVALUATION • Initial screening investigations and further investigations as suggested by history and physical examination
  • 24. MANAGEMENT OF THE CHILD WITH FAILURE TO THRIVE • The child’s diet and eating pattern • The child’s developmental stimulation • Improvement in care-giver skills • Presence of any underlying disease • Regular and effective follow up
  • 25. DIET AND EATING PATTERN • Feeding interval should not be greater than four hours and the maximum time allowed for suckling should be 20 minutes. • Eliminating distractive events • Avoiding fruit juices • For older infants and young children meals should last for about 30 minutes, solid foods should be offered before liquids, environmental distraction should be minimized not be force-fed.
  • 26. CATCH-UP GROWTH • Gaining weight at a rate greater than 50th percentile for the age. • 1.5 to 2 times the expected calorie intake for the age • Energy-dense foods
  • 27.
  • 28. Monitoring nutritional therapy • The first priority is to achieve an ideal weight- for-age. • The second goal is to attain a catch-up in length expected for the child’s age. • Effectiveness of therapy is monitored by gain in weight • Establishes the diagnosis of psychosocial FTT.
  • 30. DEVELOPMENTAL STIMULATION • Intensive environmental stimulation • Foster homes
  • 31. OTHER ASPECTS • Improvement in care-giver skills • Presence of any underlying disease • Regular and effective follow up
  • 32. COMPLICATIONS • Malnutrition-infection cycle • Cognitive disability • Re-feeding syndrome
  • 33. Re-feeding Syndrome • fluid retention, hypophosphatemia, hypomagnesemia and hypokalemia. • calories can safely be started at 20% above the child’s recent intake. • Increased by 10-20% per day • If no estimate of caloric intake is available, 50 to 75% of the normal energy requirement is safe
  • 34. PREVENTION OF FAILURE TO THRIVE • Promotion of exclusive breast feeding for early infancy • Community effort • Encouraging parenting education courses • Early detection of FTT and intervention • Prevention of low birthweight • Neonatal screening for treatable metabolic disorders