A 5-month-old female infant presented with fever and vomiting and was diagnosed with failure to thrive and an acute febrile illness. Labs showed hypothyroidism and malnutrition. The patient was started on levothyroxine and a higher calorie formula. After one week of treatment, the patient's thyroid levels normalized and intake improved, though the family was counseled to further increase calorie intake to support adequate growth.

1.  
By Emily Todhunter, WVU GDI 2012

2.  Overview of Patient
 Failure to Thrive
 Medical Nutrition Therapy for FTT
 Patient Labs
 Hypothyroidism
 Nutrition Assessment of Patient
o Nutrition Diagnosis
o Nutrition Prescription
o Nutrition Intervention
o Monitoring/Evaluation

3.  

4.  5-month old female
 Presents with fever and vomiting on 11/5
o Fever at 9:30am of 101.2*F, some improvement after
administration of Tylenol but fever then persisted at 102*F
 Saw pediatrician who referred her to the ER
o ER Course: Lab work – elevated white count (18,700) H & H low
at 10.1 and 30.5, platelet count 446,000. Urine lab normal.
o ER Treatment: Dose of Rocephin (injection used to treat
bacterial infections – Ceftriaxone)
o ER Diagnosis: 1) Acute febrile illness, viral syndrome, rule out
bacteremia 2) Failure to thrive

5.  Full-term vaginal delivery, birth weight 7 # 13 oz
 At 2 months and 1 week old, mother went back to work
 Milk production decreased, mother couldn’t pump as
often
 Baby doesn’t sit up independently
 Baby attends daycare during day
 Mother states child vomits after consuming more than
3.5 oz in one sitting
 Mother states that baby has been developing okay as far
as length and head circumference but her weight gain
has been poor
 Currently weighs 10 # 10 oz

6.  

7.  Physical sign of undernutrition, characterized by growth
rates that do not meet expected standards for infants
and toddlers under 3 years of age
 Inadequate nutrition for optimal growth
 Seen in 5-10% of US children in primary care settings
 Possible causes of FTT in children include:
o Inadequate energy intake
o Inadequate nutrient absorption
o Increased metabolic demands
o Defective nutrient utilization

8.  Increased risk for growth deficiency or short stature
 Increased susceptibility to childhood diseases
 May be at increased risk for later heart disease
 Under-nutrition during critical brain development causes
retardation of brain growth as well as a variety of
functional abnormalities in the neurons

9.  Organic FTT
o Associated with a chronic disease process or disability
o Conditions that affect digestion or absorption
o Examples: GERD (energy intake), chronic diarrhea (nutrient
absorption), cerebral palsy (metabolic demands), chromosomal
abnormalities (nutrient utilization)
 Nonorganic FTT
o Term used to describe poor growth of a child in the absence of
any medical diagnosis
o Largely environmental
o Commonly associated with delayed development, abnormal
behavior, altered infant-caregiver interaction.

10.  Most often multi-factorial.
o Psychosocial
o Environmental
o Biological
 Example:
o GERD  child upset during feeding times due to pain of acid
reflux  caregivers interpret reaction as cue to stop feeding
o GERD (organic) + Infrequent/inadequate feedings (nonorganic)

11.  Weight for age is less than 5th percentile on a standard
WHO growth chart (0-24 months) or CDC growth chart
(24+ months), with normal height/length
 Weight for length less than then 5th percentile (0-24
months) on a standard WHO growth chart and/or BMI
(24+ months) is less than the 5th percentile on a
standard CDC growth chart
 Weight is less than 80% of expected weight for
height/length
 Deceleration of growth velocity across two major
percentile lines and/or decrease of more than 2 SDs on
a CDC or WHO growth chart over a period of 3-6 months

12.  Child at or above 50th
percentile for length
both at birth and 5
months of age
 Child born at 50th
percentile for weight,
but has dropped to
below the 5th percentile
for weight by 5 months
of age
o Birth: 51.4 cm, 3.55 kg
o 5 Months: 63.5 cm, 5.06
kg

13.  By month 4-6, child should have doubled their
birthweight
 Healthy weight gain from 0-6 months is 5-7 oz/week (or
140-200 g/week)
 This child gained an average of 2 oz/week (68 g/week)
from birth to 5 months.

14.  Provide adequate nutrients and energy for appropriate
weight gain and linear growth for age
 Reinforcement of nutrition instruction to caregivers
 For 3-6 month old, monitor weight and length/height
weekly until weight gain commences
 Continue to plot on growth charts every 3 months until
child demonstrates acceptable growth curve
 Enteral nutritional support, if necessary
Age Average Average Average Average Fluid
Weight Gain Protein Energy (mL/kg/day)
(g/day) (g/kg/day) (kcal/kg/day)
3-6 months 15-25 2.2 108 125-160

15.  

16. 11/5 11/7 11/8
WBC (4.3-15.2 K/cu mm) 18.7 (H) 14.0 11.6 ↑ due to febrile
illness
RBC (3.7-5.42 M/cu mm) 3.29 (L) 3.08 (L) 3.23 (L) Slightly ↓ :
Malnutrition
Hgb (10.5-14.1 gm/dL) 10.1 (L) 9.4 (L) 9.7 (L) Blood draws
Other
Hct (31.5-42.4 % volume) 30.5 (L) 28.0 (L) 29.3 (L)
MCV (72-91 fL) 93 (H) 91 91 (Measurement of
the average size
Mean Corpuscular of red blood cells)
Volume ↑ in
hypothyroidism

17. Hema Miscellaneous 11/8
Reticulocyte Count 1.9 (H?) A measure of how many RBCs called
(0.5-1.5%) reticulocytes are made by the bone marrow
and released into the blood.
Retic count rises when there is a lot of
Children: 0.5-2.0% blood loss or in certain diseases where
RBCs are destroyed prematurely.

18.  Prealbumin: 9.0 mg/dL on 11/6
 “Normal Range” = 20-40 mg/dL
 Best indicator for malnutrition we have available, as
albumin levels were not tested.
 Indicates protein-malnutrition.
Age Normal Lab
Value
0-6 months 7-39 mg/dL
7-36 months 2-36 mg/dL
4-6 years 12-30 mg/dL
7-19 years 19-35 mg/dL
Pediatric Nutrition Care Manual

19. 11/6
Free Thyroxine (0.9-1.8 ng/dL) 0.6 (L)
TSH (0.4-6.0 μIU/mL) 1.957
 MD consult for low free T4 (11/8)
 Initiated a 1 mcg ACTH stimulation test and she had a
peak cortisol level of 53.3 which was normal.
 Prolactin level was 7.9. She had a serum osmolality of
279. The urine osmolality of 358.
 “They went ahead and did a MRI of the pituitary. The
radiologist did read this as normal however, when we
reviewed the MRI images ourselves, we felt that the
pituitary did appear to be hyperplastic.”

20.  Non neo-plastic increase in one or more functionally distinct
types of pituitary cells
 Pituitary enlargement is induced by the lack of T4 feedback
and has been reported to revert on thyroid hormone
replacement
 The incidence of pituitary hyperplasia in patients with
hypothyroidism varies from 25% to 81%
 Thyroid hormone
replacement therapy led to a
decrease in the size of the
gland in 85% of patients with
pituitary enlargement who
underwent follow-up MR
examinations
Pituitary Gland

21.  Assessment: 1) Central hypothyroidism 2) FTT 3)
Question of an abnormal pituitary MRI
 Plan: “Continue her on Synthroid 25 mcg, which she
started. She does have a growth factors are pending. I
advised the mother that we would see her back in the
office in about 1-2 weeks after discharge. We will follow
w/ her clinically after that.”

22.  Produces thyroid hormones
triiodothyronine (T3) and
tetraiodothyronine, or thyroxine
(T4) and Calcintonin
 Hormones regulate
metabolism, growth and
maturation of human body
 Production of thyroid hormones
is regulated by the pituitary
gland (which produces TSH –
thyroid stimulating hormone)

23.  Condition in which the thyroid does not make enough
thyroid hormone.
o Low free T3, T4 in the blood
o High TSH
 Symptoms include: lack of energy, depression,
constipation, slowed metabolism, weight gain, hair loss,
dry skin, dry coarse hair, muscle cramps, decreased
concentration, aches and pains, swelling of the legs, and
increased sensitivity to cold

24.  Lack of these hormones early in life can have severe
effects on a baby or child’s physical, intellectual, and
emotional development
 Will need life-long therapy
 Doctor may check thyroid levels every 2-3 months at first
 Re-check thyroid levels every year
 Energy restriction produces a transient, hypothyroid,
hypometabolic state that normalizes on return to energy-
balanced conditions (Weinsier et al., 2000)

25.  In children, initial dose of 25 mcg/day of levothyroxine
sodium is recommended with increments of 25 mcg
every 2-4 weeks until the desired effect is achieved.
 For 3-6 months of age, recommended 8-10 mcg/kg/day
o For 5.06 kg, about 40-50 mcg/day
 Peak therapeutic effect may not appear until 4-6 weeks
after initiation of therapy (due to long half-life)

26.  

27.  2 T x 2 whole wheat cereal
 2 x 30 minutes of breast feeding
 11 oz of 24 cal/oz formula (3.5 oz, 3.5 oz, 4 oz)
 = 315 calories (cereal & formula) + 60 minutes of breast
feeding
 According to NCM, typical portion sizes & daily intake for
infants 4-6 months:
o Breast milk or infant formula (6-8 oz) x 4-6 feedings/day
o Infant cereal (1-2 Tbsp) x 1-2 feedings/day

28.  11/6
o Daily Total Calories: 315 (+ 60 min breast feeding)
o 43.5% of estimated needs
o Providing 65 kcal/kg
 11/7
o Daily Total Calories: 610
o 84.3% of estimated needs
 “Pt’s intake improved yesterday (11/7), however, mom’s
record and documented intake vary. Discussed plan w/
resident, will continue w/ current formula. May consider
further concentrating formula. Await endocrinology lab
results.”

29.  “May consider asking mom to pump, add HMF or
powdered formula to expressed mother’s milk. May also
consider 27 cal/oz formula if pt. unable to consume more
volume/feed.”
 HMF: Human Milk Fortifier
o Mixed with measured amounts of human milk to provide an extra
2-4 calories/ounce (1 pkt to either 25 mL or 50 mL of human
milk)

30.  Secondary to: Admitting Diagnosis (FTT); Prealbumin <16
(9)
 Current Medical History: FTT, Febrile, Vomiting
 Braden score = 25
 No IV
 Medications: Tylenol
 Nutrition Therapy Order: Regular (lactating), infant formula 4
oz every 3-4 hours Similac Sensitive_22 calories every 3
hours, 2 Tbs cereal BID IBW/ht IBW/age Wt/Ag Ht/Age Wt/Ht
Length Weight IBW %IB
W e % %
%
63.5 cm 5.06 kg 6.7 kg 76% 6.6 kg 2 months <3rd 50th <3rd

31.  D5 NS @ 50 mL/hour over 20H
o 11/5
o 170 calories dextrose
 KCl 10 mEq in D5/NACL 0.225% (1000 mL bag) IV @ 15
mL/hr over 24 hrs
o 11/6, 11/7, 11/8
o 61.2 calories dextrose/day

32.  Estimated energy needs: 527-724 calories (108-143/kg)
o 108 x 5.06 = 527
o 108 x 6.7 = 724
o 724/5.06 = 143
 Estimated protein needs: 11-15 g (2.2-2.9/kg)
o 2.2 x 5.06 = 11
o 2.2 x 6.7 = 15
o 15/5.06 = 2.9
 Fluid: Per MD
 Nutritional Risk: Mod/High f/u 5-7 days

33. Underweight related to failure to thrive as
evidenced by 76% ideal body weight and
<3rd percentile weight for height.

34.  Nutritional Goals:
o Improve protein status
o Adequate intake
o Tolerate P.O. diet
o Promote weight gain
 Nutritional Interventions:
o Calorie count
o Encourage P.O. intake
o IPOC
o Will monitor wt, labs, and p.o. intake
 Notes: The current nutrition order provides 134 kcal/kg
on current weight (5.06 kg BW)

35.  Similac Sensitive formula
(for gas/fussiness) since
3 months of age
 In 100 calories of
formula:
o %calories from
carbohydrates: 43
o %calories from fat: 49
o %calories from protein: 9

36. 11/6 11/16
Free Thyroxine (0.9-1.8 0.6 (low) 1.1 (normal)
ng/oL)
TSH (0.4-6 ulU/mL) 1.957 (normal) 0.403 (normal)
Treatment of Synthroid 25 mg/day + 27 cal/oz formula

37. 11/5 11/6 11/7 11/8 11/9 11/9
17:47 00:04 06:16 06:00 06:00 11:48
Weight in 4.82 5.06 4.94 4.88 5.94 4.92
kg
Expected weight gain for children 3-6 months old: 15-25 g/day
(NCM)

38.  http://www.cdc.gov/growthcharts/
 http://www.mayoclinic.com/
 http://www.nlm.nih.gov/medlineplus/ency/article/003696.htm
 http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682461.html
 Pediatric Nutrition Care Manual – Academy of Nutrition and Dietetics
 Cole, S. Z., & Lanham, J. S. (2011). Failure to thrive: An update. American
Family Physician, 83(7), 829-834. Retrieved from
http://www.aafp.org/afp/2011/0401/p829.html
 Franceschi, R., Rozzanigo, U., Failo, R., Bellizzi, M., & Di Palma, A. (2011).
Pituitary hyperplasia secondary to acquired hypothyroidism: case report.
Italian Journal of Pediatrics, 37(15), doi: 10.1186/1824-7288-37-15
 Passeri, E., Tufano, A., Locatelli, M., Lania, A. G., Ambrosi, B., & Corbetta, S.
(2011). Large pituitary hyperplasia in severe primary hypothyroidism.
The Journal of Clinical Endocrinology & Metabolism, 96(1), 22-23. doi:
10.1210/jc.2010- 2011
 Weinsier, R. L., Nagy, T. R., Hunter, G. R., Darnell, B. E., Hensrud, D. D., &
Weiss, H. L. (2000). Do adaptive changes in metabolic rate favor weight
regain in weight- reduced individuals? an examination of the set-point
theory. The American Journal of Clinical Nutrition, 72(5), 1088-1094.
Retrieved from http://ajcn.nutrition.org/content/72/5/1088.long