- Failure to thrive is defined as inadequate physical growth diagnosed by observing growth trends on standard growth charts. - It can be classified as organic (caused by medical issues) or nonorganic (caused by psychosocial factors) and further divided into prenatal or postnatal categories. - Evaluating a child for failure to thrive involves taking a thorough history including feeding and medical history, performing a physical exam, and ordering basic screening labs tailored to the child's history and exam findings. - Treatment focuses on increasing caloric intake to promote catch-up growth, addressing any underlying medical issues, modifying feeding behaviors, and involving psychosocial support services if nonorganic causes are suspected.

1. Failure to Thrive Shannon Pittman, M.D. University of Mississippi Jackson, MS

4. http://www.peacecorpsonline.org/messages/messages/2629/1008996.html

5. http://bluegoldfish.blogs.com/surface/2004/05/present_from_pr.html

6. http://www.babybabyphoto.com/family/pages/02baby_flowers.htm

7. http://www.kindersigns.com/images/corbis-black-baby.jpg

8. Objectives To define failure to thrive (FTT) To identify major classification of FTT To discuss diagnostic workup of FTT To discuss treatment of FTT

9. Things We Will Not Cover Geriatric FTT Am Fam Physician. 2004 Jul 15;70(2):248, 257. Rehabil Nurs. 2005 Jul-Aug;30(4):152-9 Adolescent FTT

10. Things We Will Not Cover Other specific causes (e.g.) Congenital defects Celiac disease HIV/AIDS Metabolic disorders CHF (reference for Jenny) Prog Pediatr Cardiol. 2000 Sep 1;11(3):195-202.

11. Why Do We Have to Talk About it at All? Personal Depending on current status in app. 9, 21, or 32 months you will sit for the ABFP (13%-pediatrics) ACGME competencies / AAFP core recommendations Patients Parental concerns Doc, is my baby growing right? Cognitive development Arch Dis Child. 2005 Sep;90(9):925-31. Epub 2005 May 12. J Child Psychol Psychiatry. 2004 Mar;45(3):641-54.

12. Clinical Vignette 15 month old admitted with lethargy from dermatology office Prior to admit, several days of decreased activity Med hx remarkable for eczema, treated with topical steroids

13. Clinical Vignette Wgt and ht both below 5 th percentile, but had grown along the 25 th percentile until age 4mo Extensive erythematous plaques on her back, diaper region, thighs, and polpliteal fossa bilaterally

14. Clinical Vignette What concerns you about this child What history questions should you ask What labs would you order How would you manage pt’s care

15. Okay, Tell Me What Happens Next - Afternoon clinic 10 Patients scheduled Everyone of them showed up Your 5 th pt is new & has a typed list It’s 4:00 and you are on pt 6 who happens to be a 9 mo well child

16. http://www.cha.state.md.us/edcp/html/immpg.html

17. We’re not alone In England, 54% of GP failed to diagnosis FTT Residency clinic, 41% with delayed dx Residency clinic, 29 dx, 100% dx incorrectly

18. FTT – Definition “Inadequate physical growth diagnosed by observation of growth over time using a standard growth chart”

19. Normal Growth Average wgt 7 lbs (3kg) Double by 4 months, triple by 12 Grow 25 cm in length during 1 st year Make sure you have the right chart Premature Breastfeeding www.cdc.gov/growthcharts

20. FTT Criteria Ht/Wgt less than 3 rd to 5 th percentile for age on >1 occasion Ht or Wgt falling 2 major percentiles Below 10 th percentile for ht/wgt < 80% of ideal body wgt for age Head circumference important, but not part of FTT entity

21. FTT HISTORY ! HISTORY! HISTORY! Prenatal Feeding # oz needed in 24 hours Wgt (kgs) x 5 (need 100 kcal/kg/day) How formula prepared Good diet history (3 day journal) Bowel habits

22. FTT Physical Gomez Criteria <60 = severe; 61-75 = mod; 76-90 = mild Kwashiorkor – protein malnourishment Marasmus – caloric deficiency Short Stature Syndrome Constitutional Delay

23. FTT - Classification Organic FTT Pre/postnatal Nonorganic FTT (NOFT) Pre/postnatal Mixed (25%)

24. FTT - Classification Organic FTT Prenatal Causes Prematurity w/complications Toxic exposure Postnatal Inadequate intake Lack of appetite Inability to suck/swallow

25. FTT - Classification Organic, postnatal cont. Poor absorption and/or use of nutrients GI disorder (celiac, CF) Inborn errors of metabolism Increased metabolic demand Hyperthyroidism Chronic Disease

26. FTT - Classification Nonorganic Prenatal Malnourished mother ? Lack of prenatal bonding Postnatal Poor feeding skills/disorder Dysfunctional family Difficult parent-child interactions Difficult Child Abuse/Neglect

28. Recap - Classification Failure to Thrive Organic Nonorganic Prenatal Postnatal Toxic Exposure Inborn errors Prenatal Postnatal Malnourished mother Abuse/Neglect

29. FTT - Workup +/- Basic screening labs CBC, Chemistry, & UA Specific test directed by history HIV, ESR, TSH, Sweat chloride test, serum IGF-I, serum IgA/IgG antigliadin antibiodies X-rays for bone age

30. FTT – Treatment High calorie diet for catch up growth 150% of recommended daily caloric intake based on expected wgt +/- Feeding behavior modification Psychosocial involvement/ intervention Close follow up Physical and cognitive delays Hospitalization when necessary

31. Clinical Vignette 15 month old admitted with lethargy from dermatology office Prior to admit, several days of decreased activity Med hx remarkable for eczema, treated with topical steroids

32. Clinical Vignette Wgt and ht both below 5 th percentile, but had grown along the 25 th percentile until age 4mo Extensive erythematous plaques on her back, diaper region, thighs, and polpliteal fossa bilaterally

33. Clinical Vignette What concerns you about this child What history questions should you ask What labs would you order How would you manage pt’s care

34. Summary: G.R.O.W.T.H. G ather history and extensive physical R emember genetic contribution O nly order basic labs in initial eval W onder about zebras T rack growth trends H ospitalize or hormonally treat

35. Take Home The keys to diagnosing FTT is finding the time to accurately measure and plot wgt/ht and then access the trend

36. http://www.cha.state.md.us/edcp/html/immpg.html Afternoon clinic 10 Patients scheduled Everyone of them showed up Your 5th pt is new & has a typed list It’s 4:00 and you are on pt 6 who happens to be a 9 mo well child

37. Any Questions? www.child.com/.../ baby_babble.jsp

38. References Listernick, R. (2004). Accurate feeding history key to failure to thrive. Pediatr Ann , 33:3, 161-9. Burgos, R., Jutte, D. (2000). Resident’s column: “doctor, is my child growing ok?”. Pediatr Ann , 29:9, 585-7. Krugman, S., Dubowitz,H. (2003). Failure to thrive. American Fam Phy, 68:5, 879-84. Schwartz, R., Abegglen, J. (1996). Failure to thrive: an ambulatory approach. Nurse Pract, 21:5, 19-31. Careaga, M., Kernder, J. (200). A gastroenterologist’s approach to failure to thrive. Pediatr Ann . 29:9, 558-67. Bassali, R., Benjamin, J. (2004, August 11). Failure to Thrive. eMedicine. Retrieved September 17, 2005, from http:///www.emedicine.com/ped/topic738.htm.

39. Thanks for Your Attention! www.jade-designs.org/ tubetotin/jababybottom.gif