failure to thrive (1).pdf

LEARNING OBJECTIVE
1. Identify normal growth pattern in a child.
2. Deﬁne and discuss the causes of failure to thrive in a child.
3. Demonstrate the importance of feeding history.
4. Explain the principles of nutrition in a child.
5. Plot and interpret growth parameters on a growth chart.
6. Describe the nutritional requirements of normal growth.
7. Formulate the approach to management of a child with failure to thrive.

CASE PRESENTATION
A 1 year 9 month old boy with history of prematurity at 31
weeks of gestation was diagnosed with spastic diaplegia
cerebral palsy at age of 1 year old and was admitted in
Cheras Rehabilitation Hospital for physiotherapy.

History of presenting illness
●Admitted to CRH for physiotherapy.
●Initial presentation with delayed in standing at one year old, was unable to
pulls to stand at that age.
●Upon stepping with support, mother noticed tip toeing of left foot.
●It is associated with stiﬀness of the left foot.
●However, no history of seizures, fever, vomiting, feeding diﬃculty or head
trauma.

Past medical history
●Nil
Past surgical history
●Nil
Allergy and drug history
●No allergy history

Antenatal history
●At 28 weeks of gestation,
○ diagnosed with pre-eclampsia
○ admitted for blood pressure monitoring, bed rest and diet control.
○ Not initiated on anti-hypertensive drug
○ Discharged after 4 days of admission.
●At 31 weeks of gestation,
○ Noticed to have intrauterine growth restriction and reduced in liquor volume
○ CTG: showing fetal in distress.
○ emergency lower segment caesarean section.

Birth history
●born premature at 31 weeks of gestation via emergency lower segment
caesarean section.
●Birth weight was 1.146 kg with Apgar score 2 in 1 minutes, 6 in 5 minutes
and 8 in 10 minutes.
●Patient was admitted to NICU after delivery.

Postnatal history
●In NICU, patient was intubated for 5 days.
●He was in incubator for 33 days in NICU.
●MRI of brain was done, showed right intraventricular hemorrhage stage IV,
was on conservative management.
●He was on Ryle’s tube for feeding. No history of poor feeding or
regurgitation of milk.
●Gain weight approximately 37 g per day and was discharge after 51 days in
hospital with birth weight of 1.9 kg.

Immunization history
●Completed all vaccine up to age with additional pneumococcal vaccine

Diet history
●Exclusively breastfed until 6 month old.
●Started formula milk at 6 month old, mixed with breastfeeding for 3 month,
then stopped and changed back to breast milk due to refusal from the child
to formula milk.
●Complementary diet started at 6 month, with porridge 3 times a day.
●Porridge was prepared one small bowl of rice with vegetables and chicken
or beef that was minched into small pieces.
●Had biscuit and fruits in between meals.
●He was also breastfed on demand until now with 8 ounces of milk
approximately 3 times per day.

Developmental history
●Gross motor
○ Can turn over body from supine to prone around 5 month old and from prone to supine at 6
month old
○ Sit without support at age 10 month
○ Able to pulls to stand at 15 month
○ Crawling up stairs and comes down backwards at 18 month old
●Fine motor and vision
○ Able to grasp object at 5 month old
○ Transferring objects from hand to hand 10 month
○ Mouthing at 10 month old
○ Attentive to objects and people in environment

●Hearing and speech
○ Turned to sound at 10 month old
○ Turns to mother’s voice across the room at 10 month old
○ Able to say word, abah at 12 month old
○ Understand no and bye-bye at 15 month old
●Social behaviour
○ Able to reaches out for objects, manipulates it, mouths and transfers at 18 month
○ Able to holds, bites and chew biscuit at 10 month old

Family history
● Parents are healthy
● No history of consanguinity
● This is their ﬁrst child
● No other family members with same problem
Social history
● Mother (29 y/o) previously working as software tester but resigned in
February this year to take care of the child.
● Father is an engineer and often work abroad.
● Financially stable.
● Lives in Segambut with her Grandparent.

Physical examination
●General examination
○ Pink, alert and conscious
○ Small built and not appropriate to age
○ No dysmorphism
○ Not in respiratory distress or obvious pain
●Vital signs
○ Respiratory rate : 28 bpm
○ Pulse rate : 110 bpm
●Growth parametes
○ Length : 77 cm
○ Weight : 8.3 kg
○ Head circumference: 44 cm

●Hands and facies
○ Capillary reﬁll time <2 seconds
○ Warm peripheries
○ No conjuctival pallor and scleral jaundice
○ Strabismus of the right eye
○ No central cyanosis or dental caries
●Lower limb examination
○ No scar, deformity or muscle wasting
○ Normal tone for both lower limb
○ Hyperreﬂexia for both lower limb
○ Upon standing with support, tip toeing noted on the left foot

SUMMARY
●A 1 year 9 month old boy with history of prematurity at 31 weeks of
gestation complicated with right intraventricular hemorrhage stage IV
diagnosed with spastic diaplegia cerebral palsy at 1 year old with global
developmental delay. Clinical examination showed hyperreﬂexia of both
lower limb and tip toeing ever the left foot.

1. THE NORMAL GROWTH
PATTERN IN AN INFANT

Normal growth pattern
• 4 phases of normal human growth.
• Male and female height velocity chart showing the
determinant of childhood growth.
• The fetal and infantile phase are mainly dependent on
adequate nutrition whereas childhood and pubertal phases are
dependent on general health, and other growth hormones.

● Normal growth is the progression of changes in
height/length, weight and head circumference that are
compatible with the established standard of given
population.
● Serial measurements are much more useful than a single
measurement to detect standard deviation from a
particular growth pattern, even if the value remains within
statistically deﬁned normal limits (percentile).
● Growth is assessed by plotting accurate measurement in
growth charts and comparing each set of measurement
from the previous measurements obtained.
● When caloric intake is inadequate, the weight percentile
falls ﬁrst, then the height, followed by head circumference
as the last.

Growth Parameter
●Weight
❖Measured using electronic weighing device
❖In unit = Kilogram (kg) or Pound (lb)

●Height / length
❖Height : children able to stand upright (more than 2 Y/O)
❖Length : measured lying down (less than 2 Y/O)

●Head circumference
❖Use measuring tape that is soft and non- stretchable.
❖occipitofrontal circumference is measured from above
eyebrow – above ear – occipital region. 3 measurements
have to be taken and the mean is calculated for the more
accurate reading.

Learning issue 2:
Deﬁne and discuss the causes of failure
to thrive in an infant.

●Failure to thrive- is a term given to malnourished infants and young
children who fail to meet expected standards of growth.
●Diagnosed by weight that falls or remains below the 3rd
percentile for
age; that decreases, crossing two major percentile lines on the growth
chart over time or less than 80% of the median weight for the height of
the child.

Learning issue 3:
Demonstrate the importance of feeding
history.
References:
1. Nelson’s Essential of Paediatrics 7th
Edition
2. https://enea-sea.med.lmu.de/
(Early Nutrition eAcademy Southeast Asia
eLearning)

Infant and Young Child Feeding: Model Chapter for Textbooks for
Medical Students and Allied Health Professionals.
FIGURE 1: Major causes of death in neonates and children under five in the world, 2004
Sources: World Health organization. The global burden of disease: 2004 update.

History taking in failure to thrive
What to ask ?
● global developmental delay (gross & fine motor skills,
hearing, speech & language and social skills)
● delayed secondary sexual maturation (adolescent stage)
● constipation (poor feeding)
● excessive sleepiness (lethargy )
● irritability

Birth history - intrauterine insults (IUGR), prematurity, birth weight,
infective screening, exposure to harmful agents (smoking, alcohol).
Past medical history - frequency of acute or chronic illness, past
hospitalisations, previous medical conditions
Feeding history - quantity of milk consumed, feed preparation, weaning
(when, what & quantity), dietary recall and diary.
Family history - maternal & paternal height, growth of other family
members & any illness in family (familial short stature)
Detailed social history - parental (depression, marital disharmony,
substance abuse, unemployment, poverty) , food insecurity/ shortage,
living condition, psychosocial problem, abuse, neglect

Consequences of malnutrition
● Malnutrition during the first 2 years of life will cause stunting
● Immunity will be impaired and wound healing will be delayed
● Worsen the outcome of illness
● Can cause delay in intellectual development
● They become less active

Breastfeeding history
o Onset of breastfeeding
o Frequency of breastfeeding (How many times per day ? How many hours?)
o Exclusive breastfeed or mixed breastfeeding? Reasons?
o Duration of each feed?
o Changes over a period of time?
o Quality of breastfeeding? –does baby show cues of hunger etc crying,
looking for breastmilk, mouthing/ sleeping?
o Storage of breastmilk. Causes of growth failure early in infancy:
1. Lactation problems in breastfed infants
2. Improper formula preparation-water it
down or make it too concentated, it
disturbs the electrolyte balance.

Formula Feeding history
o Onset of formula feeding?
o What kind of infant formula?
o Amount (how many ounces and scoops for each feed)
o Frequency of formula feeding (how many times a day ? How many hours?)
o Change in amount & frequency? (over a period of time)
o Preparation of feeds? – does parents follow the proper instructions/add too
little/too much water?

Breast Milk Substitutes (BMS)
o formula is over-diluted,
🡪insuﬃcient intake of energy
and nutrients
o formula too
concentrated🡪dehydration,
diarrhea & excessive intake of
energy 🡪overweight or obesity
Breast milk of mother: 67 kcal/ 100mls
P22: 22kcal/fl oz
P24: 24kcal/fl oz

Powdered Infant Formula
●majority of BMS-fed infants receive PIF.
●PIF is not a sterile product and can be intrinsically contaminated with
harmful bacteria, for example:
●Cronobacter sakazakii (previously known as Enterobacter sakazakii)
●Spread via:
●contaminated spoons or blenders
●extended storage of bottled formula in bottle warmers, which allows
bacteria to proliferate for extended periods at an ideal temperature
(Agostoni et al. 2004)
●Salmonella enterica
(Carletti & Cattaneo 2008; Cahill et al. 2008)

Bottle hygiene history
o Ensure bottled milk is prepared in a clean environment using clean
bottle, nipple, ring and cap.
o Cleaning of bottles used for feeding including nipples, rings, and caps.
● Wash hands well with soap and water.
● Separate all bottle parts.
● Rinse under running water, wash using soap and scrub using a clean
brush.
● Allow to air dry.
● Sanitize feeding items atleast once daily, by placing disassembled
feeding items into a pot and cover with water, ensure all items are
fully submerged, bring the water to a boil, boil for 5 minutes and
remove items with a clean tongs.
● Allow to dry and store properly for next use.

Complementary Feeding history
●Onset?
●Types of foods introduced- cereal, fruits, vegetables, eggs, home
cooked food- new food should be offered once a day in a small
amount (1-2 tablespoons).
●Frequency?
●Ask in detail: Breakfast, lunch, dinner, snacks in-between
●Food recall- proper balanced diet includes all food groups
●Food allergies?
●Picky eater?

Older infants and children
●Range and type of foods now taken
●Mealtime routine
●Eating and feeding behaviours
●Dietary recall and diary
Causes of growth failure early in older infants and
children:
1. Inappropriate restricted diets due to parental
dietary beliefs (vegetarian, vegan)
2. Distractions that interfere with completing meals

The Principle of Infant
Nutrition

A. Exclusive breastfeeding
(birth → 6 month old)
●Act of feeding infants solely with breast milk, includes feeding of expressed
breast milk.
●Soon after birth unless medical conditions preclude them.
●An exclusively breastfed infant should not be given any other ﬂuid including
plain water.

●In the 2-5 days postpartum,
●Thin, yellowish substance called colostrum
●Electrolyte-, macrophage-, and nutrient-rich substance
with a premilk composition.
●Volume of colostrum produced varies for every mother.

Adequacy of milk intake
● Voiding and stooling patterns of the infant
○ Voids ﬁve to six times a day
○ Soak, not merely moisten a diaper
○ Pale colored urine
●Rate of weight gain provides the most objective indicator of adequate
milk intake
○ Total weight loss after birth should not exceed 7%
○ Birth weight should be regained by 10 days
○ Usually with adequate amount of milk, they gain 20g/day
●They will also feel contented about 1 hour after every feed.

●Loose yellow stools
○ at least 3 - 8x a day
●Stool frequencies vary; during the ﬁrst 4 to 6 weeks, breastfed
infants tend to produce stool more frequently than formula-fed
infants.
●After 6 to 8 weeks, breastfed infants may go several days
without passing a stool.

Inadequate Milk Intake
Insufficient milk intake, dehydration, and jaundice in the infant can
surface after the first 48 hr of life. The infant might cry or be
lethargic and have delayed stooling, decreased urine output,
weight loss >7% of birth weight, hypernatremic dehydration, and
increased hunger.
Insufficient milk intake may be due to
○ insufficient milk production or failure of established
breast-feeding
○ health conditions in the infant that prevent proper breast
stimulation.
Parents should be counselled that breast-fed neonates must feed a
minimum of 8 times per day.

B. Formula feeding
● The caloric density of formulas are 20 kcal/oz (0.67 kcal/ml) which is
similar to human milk
● Various types of formula milk available in the market
● Most milk-based formulas have added iron and parents should only
use iron fortiﬁed formula unless advised otherwise
● Soy- based formulas may be used for infant who are allergic to cow’s
milk
However, there are certain of them who are also allergic to the protein
in soy based milk
Thus, hypoallergenic formulas are given

C. Complementary feeding
●Process starting when breast milk or infant formula alone is no
longer suﬃcient to meet the nutritional requirements of infants,
and therefore
○ other foods and liquids are needed, along with breast milk or
a breast-milk substitute (WHO 2013).
●Target age : 6 months of age
●Aim: to prevent malnutrition, as well as to promote optimal
growth and development.
https://enea-sea.med.lmu.de/course/view.php?id=71

Importance of complementary feeding

Gaps to be ﬁlled by complementary foods for a breastfed
child 12-23 months.
Source: WHO 2009.
Energy required by age and the amount provided for by
breastfeeding.
Source: WHO 2009.

Appropriate complementary feeding principles can be summarised with the acronym
“ATAS” below.
● Adequate :Foods should provide sufficient energy, protein, and micronutrients to meet a
growing child’s nutritional needs
● Timely :Foods should be introduced in a timely manner based on the infant's need for
energy and nutrients. Delay in initiating CF will result in inadequate nutrition while
initiating CF too early will lead to problems such as excessive weight gain.
● Appropriate :Foods should be given responsively- consistent with a child's signals of
appetite and satiety-, and that meal frequency and feeding method - actively encouraging
the child to consume sufficient food using fingers, spoon or self-feeding- are suitable for
age.
● Safe :Foods should be hygienically stored and prepared, and fed with clean hands using
clean utensils and not bottles and teats.
General feeding principles in Infant

Feeding Principles in Infant and Younger Children
1. Practise exclusive breastfeeding from birth to six months of age.
Complementary foods must be given at six months of age while
continuing to breastfeed until two years of age.
2. Introduce complementary foods to breastfed and non-breastfed infants
beginning at six months of age. Breastfeeding on demand must be
continued until the baby is two years of age.
3. Give adequate food to meet the energy needs. Increase the amount of
food according to age.
○ Give energy dense foods including cereals, such as rice, wheat and tubers (potatoes
and sweet potatoes) to infants and young children.
○ Start with a small amount of food and as the child adapts, gradually increase the
quantity of food according to age.
○ As a guide, infants aged 6 - 8 months should be given ½ cup of thick rice porridge
at each meal. This should be increased to 1 cup between the ages of 9 - 11 months.
Children 1 - 3 years should be given ½ cup of rice at main meals. In addition, 1 - 2
teaspoons of oil should be added in a day meals for all age groups.
Guidelines for the Feeding of Infants and Young Children by Nutrition Division Ministry of Health Malaysia 2008

4. Give a variety of foods to ensure that all nutrient needs are met. Meat, poultry,
ﬁsh, eggs, milk and dairy products should be given frequently.
○ The type and quantity of food given must meet the daily nutrient requirements particularly those of
protein, fat, calcium, iron, vitamin A and vitamin C.
5. Gradually change food texture and preparation methods as the infant gets
older, adapting to the infant’s development and abilities.
○ Infants aged 6 to 8 months must be given pureed, mashed and semi-solid foods. At 9 to 11 months,
infants should be fed on chopped foods. Finger foods such as soft biscuits and fruits can also be
given. At 12 months, infants can eat family foods.
○ Give foods of appropriate texture to avoid choking. Children should be supervised during mealtimes
and potential choking hazards kept out of reach.Caregivers should be equipped with basic knowledge
on choking rescue procedures.

6. Increase the feeding frequency according to age.
○ Complementary foods should be given at the following frequencies according to age:
i. 6 – 8 months : 2 - 3 times/day with 1 - 2 nutritious snacks
ii. 9 – 11 months : 3 - 4 times/day with 1 - 2 nutritious snacks
iii. 1 – 3 years : 4 - 5 times/day with 1 - 2 nutritious snacks
○ Increase the frequency of meals if the amount of food consumed is less or the food is diluted
(less energy-dense).
7. Practise responsive feeding, applying the principles of psycho-social care.
○ Feed infants directly and assist young children when they feed themselves.
○ Feed infants and young children slowly and patiently. They should be encouraged to eat and
not forced.
○ Be sensitive to the hunger and satiety cues of infants and young children.
○ Build a positive and loving relationship with infants and young children in a conducive and
comfortable environment. Interact with them during meal times.

8. Practise safe preparation, handling and storage of food.
○ Personal hygiene, cleanliness of cooking utensils and food must be ensured at all stages of food
preparation and feeding of infants and young children.
○ Wash hands properly before preparing foods and after using the washroom.
○ Infants’ and young children’s hands should also be washed thoroughly before eating.
○ Cooked food must not be left at room temperature for more than 2 hours.
○ However, freshly cooked foods can be stored for up to 24 hours in the refrigerator (3°C or lower) or one
month in the freezer (0°C or lower).
9. During illness, give infants and young children more water and other fluids. Offer
small but frequent meals.
○ Continue and practise frequent breastfeeding.
○ Offer the child his favourite foods.
○ Encourage the child to eat soft, varied and appetising foods.
○ After illness and during recovery, give extra food more often than usual and encourage the child to eat
more.

Source: ENeA-SEA own, adapted from National Coordinating Committee on Food and Nutrition 2017.

Practical guidance on the quality, frequency and amount of food to offer children 6-23 months of age who are
breastfed on demand.

Dietary diversity is also an important
factor to consider with regards to
complementary feeding. Minimum
dietary diversity should include at least
four of the following 7 food groups:
●Grains, roots and tubers.
●Legumes and nuts.
●Dairy products (milk, yoghurt,
cheese).
●Flesh foods (meat, ﬁsh, poultry,
liver/organ meats).
●Eggs.
●Vitamin A-rich fruits and vegetables.
●Other fruits and vegetables.
Figure 5: Examples of food groups and their relative
proportions for complementary feeding.
Source: ENeA-SEA own

Plotting and Interpreting
Growth Parameters from
Growth Chart

● The curves
○ Selected percentiles of the reference population
○ Identify the child’s rank relative to other children of
the same sex and similar age
○ E.g. : 90th percentile for weight-for-age, it means that
only 10 of 100 children (10%) of the same age and sex
in the reference population have a higher
weight-for-age.

● Normally, serial height and weight measurements follows a ‘channel’ /
between the same percentile(s).
● Usually moving toward the 50th percentile line.
● Two or more percentile lines downwards is considered to be reﬂective
of failure to thrive or growth failure.
● Single plotted measurements - cut-oﬀ values and corresponding
nutrition indicators.

Interpretation
He has failure to thrive and small for his age.
This can be seen through his serial height, weight and head circumference
measurements.
They were all progressively increasing but on the lowest percentiles (0.4th
and below)
More than 0.4% or approximately 99.6% children of the same age and gender
has higher growth than the boy.
His height, head circumference and weight at 21 month old are 78 cm, 44 cm
and 8.5 kg respectively.

Describe the nutritional
requirement of normal growth

Types of nutrients needed
●Divided into macronutrients and micronutrients
●Macronutrients
Comprised of carbohydrates, protein and fat
●Micronutrients
Comprised of minerals and vitamins

Nutrients Function Effect of deficiency Food source
Carbohydrates ● Energy for growth
● Maintain health body
weight
● Healthy brain development
• Growth retardation
• Weakness
Starches, sugar
Fats ● Support muscle movement
● Fuels child with energy
● Brain development and
membrane structure
● Facilitate absorption fat
soluble vitamin
• Fatigue and weakness
• Mental retardation
• Growth deficit
Infant: Human milk, infant
formula
Children: butter, margarine,
vege oils,fish,seeds,nuts
Proteins ● Build and repair new tissues
● Produce enzymes,
hormones and
antibodies
• Kwashiorkor
• Marasmus
Animals-Meat , poultry, fish,
egg, milk
Plant-Legumes, nuts, seeds,
Macronutrient

Nutrients Function Effect of deficiency Food source
Fibre ● Reduce risk coronary
heart disease
● Assists maintaining
normal blood glucose level
●Improve laxation
• Constipation
• Diverticulosis
Grains: Oats, wheats,
vegetables fruits
Fibre

Nutrients Function Effect of deficiency Source
Vitamin B1 (Thiamine) ● Energy metabolism
● Muscle contraction
-conduction of nerve
signals
• Beri-beri Whole grain product,
bread, cereals
Vitamin B2 (Riboflavin) ● Helps body break down
carbohydrates, protein
and fats to provide
energy
Ariboflavinosis
• Glossitis
• Cheilosis
• Anaemia
Organ meats, milk,
bread, fortified cereals
Vitamin B3 (Niacin) ● Energy metabolism • Pellagra Meat fish poultry,
whole-grain breads
Micronutrients

Vitamin B6 ● Coenzyme in
metabolism of amino
acid, glycogen and
sphingoid bases
• Neurological
disorder including
convulsion and
epileptic
encephalopathy
Cereals, organ meat
Vitamin B5(Pantothenic
acid)
● Coenzyme in fatty
acid metabolim
• None reported Chicken beef potato
oats cereal tomato egg
yolk, broccoli
Vitamin B7 (biotin) ● Coenzyme in
synthesis of fat,amino
acid, glycogen
• Alopecia
• Dermatitis
• Hypotonia
Liver, fruits and meats

Nutrient Function Effect of deficiency Source
Vitamin B9(folate) ● Coenzyme in nucleic acid
metabolism
• Megaloblastic anaemia
• Neural tube defect
Dark leafy vegetables, whole
grains breads
Vitamin B12 (cobalamin) ● Coenzyme in nucleic acid
metabolism
• Megaloblastic anaemia
• Peripheral neuropathy
Fortified cereals, meat, fish,
poultry
Vitamin C (ascorbic acid) ● Protective antioxidant • Scurvy Citrus fruits, tomatoes,
broccoli, spinach

Vitamin A ● Normal vision
● Immune system
• Immune-compromised Liver, dairy product, fish,
dark-coloured fruits, leafy
vegetables
Vitamin D ● Calcium and bone
metabolism
• Rickets
• Osteomalacia
Sunlight exposure,cow milk
product
Vitamin E ● Antioxidant • Poor nerve impulse
transmission
• Muscle weakness
Vegetable oil, grains, nuts
Vitamin K ● Blood clotting
● Bone metabolism
• Blood coagulation defect Green vegetables, spinach,
broccoli

Calcium ● Strong bone formation
● Nerve conduction and
muscle stimulation
• Muscle weakness
• Osteomalacia
• Stunted growth
Dairy products,
anchovies
Iron ● Transport oxygen
throughout whole body
• Iron deficiency
anaemia
• Neurocognitive
deficit
Liver, red meats, milk,

Water maintains homeostasis in the body, allow transport of nutrient to cells, removal of waste product of metabolism
Water

Formulate approach of
management

Non-organic Organic
Direct practical
advice following
observation
Home visit by
health visitor
- Assess eating
behaviour and
provide support
Speech and
language therapist
- Feeding disorder
therapy
Nursery
placement
Paediatric dietician
- Assess quantity &
composition of food intake
- Recommend strategies to
increase energy intake
Clinical
psychologist &
social services
Specific treatment of the underlying diseases
➔ Medical treatment
➔ Surgical treatment
Sufficient nutrition
➔ Caloric supplementation
➔ Depend on severity and underlying
medical problems
Long term
monitoring and
follow up
Long term
social support

Strategies for Increasing Energy Intake
Dietary
- 3 meals and 2 snacks each day
- Increase number and variety of
foods offered
- Increased energy density of
usual foods (eg. Add cheese,
margarine, cream)
- Decreased fluid intake,
particularly squash
Behavioural
- Have meals at regular times,
eaten with other family
Members
- Praise when food is eaten
- Gently encourage child to eat,
but avoid conflict
- Never force-feed

Indications for hospitalizations
Severe malnutrition
Signs of child abuse, neglect, poor
parental understanding or psychosocial
concerns
Failure of outpatient management
The child must be re-fed carefully with an incremental increase
in calories to avoid re-feeding syndrome.
1. Caloric supplementation
- Based on severity of FTT & underlying conditions
2. Multivitamin supplementation
- To meet the recommended dietary allowance
- because these children commonly have iron, zinc, and vitamin
D deficiencies, as well as increased micronutrient demands
with catch-up growth

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