FAILURE_TO_THRIVE3.pptx

IDENTIFY NORMAL
GROWTH PATTERN IN
AN INFANT

WEIGHT
• Lose 10-15% of their birth weight in first 7-10 days of life
due to:
I. Excretion of excess extravascular fluid
II. Possibly poor intake (intake improves as colostrum is
replaced by higher fat milk, as infant learn to latch on
and suck more efficiently, and as mother become more
comfortable with geeding technique)
• 1st 3months of life, rate of weight gain 25g/day
• Babies usually regain their birth weight by 2nd week
• Double birth weight by 5 month age
• Triple birth weight by 1 year of age
• Weight estimation for children
– infant (age in months x 0.5 )+4

© 2010 Royal College of Paediatrics and Child Health
www.growthcharts.rcpch.ac.uk
Measuring and plotting
Measuring Weight
Babies should be weighed without any
clothes or nappy
Children older than two years can be
weighed in vest and pants, but no shoes,
footwear, and dolls or teddies in hand
Only class III clinical electronic scales in
metric setting should be used
Class III
Clinical
Electronic
Scales

HEAD CIRCUMFERENCE
• At Birth - 13.5 inches (35 cm)
• rate of growth in preterm infant is
1cm/week but reduce with age. head
growth follow that of term infant when
chronological age reach term
• COH increase 12 cm in 1st year of life (6
cm 1st 3 months, 3cm in second 3 months
and 3 cm in last 6 months)
• 5-12 y 0.33cm/year

Measuring Head Circumference
Head circumference should be
measured using a narrow plastic or
disposable paper tape
Measurement should be taken
where the head circumference is
widest

LENGTH
• Preterm infants = average 0.8-
1.0cm/week.
• Term infants = average 0.69-
0.75cm/week.
Age Length
Birth 50cm
6 months 68cm
1 year 75cm
3 years 90cm
4 years Double birth length (100cm)
5 – 12 years 5 cm yearly

Measuring Length
Measure length before age 2 years if concerned.
Length should be measured without nappy or footwear.
Use proper equipment (length board or mat) as any other
method is too inaccurate. Requires two measurers

HOW TO PLOT GROWTH
PARAMETERS ON A
GROWTH CHARTS

Plotting the Chart
• Record measurement and date in ink, plot in pencil
• Use dot; do not join up
• Age errors are commonest source of plotting mistakes
use a calender or date wheel to calculate age
– Age in weeks for first 6-12 months
– Calendar months thereafter
• Count forward from the date of birth to current month using day of
birth eg if date of birth is 26/6/09, then age 13 months is on 23/7/10)

What do the Centiles Show?
• Optimum range of weights and heights
• Describes the percentage expected to be below that line
– 50% below 50th
– 91% below the 91st
– 1 in 250 below 0.4th
• Half of all children should be between 25-75th centile

Centile Terminology
If the point is exactly on the
centile line, or within ¼ of a
space of the centile line, the
child is described as being
‘on the X centile’ (see A)
e.g. on the 91st centile.
If not they should be
described as being ‘between
centile X and Y’ (see B) e.g.
between the 75th-91st centile.

Centile Spaces
A ‘centile space’ is the
distance between two centile
lines (e.g. C).
Two measurements can be
described as a centile space
apart if they are both midway
between centiles (e.g. D).
Falls or rises should be
expressed as multiples of
centile spaces (e.g. a fall
through 2½ centile spaces).

Measuring and plotting: Activity 2 Answers

WHO GROWTH CHART RECOMMENDED CUT OFF CRITERIA
INDICATORS FOR FURTHER ASSESSMENT

INTERPRET GROWTH
PARAMETERS ON A
GROWTH CHART

• Length in our patient:
-25th centile at birth
- Increase to between 25th and 50th
centile at 3rd months of life
- Constantly between 25th and 50th
centile till 10 months of life.
• Her length is equivalent and
appropriate to the age.

• Weight
– 10th centile at birth till 1 month
– Drop to between 3rd to 10th centile for the
next 2 months
– On the 3rd centile during 6th month of life
– Below 3rd centile during 9th and 10th month of
life
• Thus there is failure to thrive.

DEFINE AND DISCUSS
THE CAUSES OF
FAILURE TO THRIVE IN
AN INFANT

DEFINITION
Given to malnourished
infants & young children
who fail to meet expected
standards of growth : Fails
to gains weight / length /
head size / development.
Related to organic,
environment and
psychosocial causes.
Nelson, essential of Peadiatrics, 6th edition.

DEFINITION
Suboptimal weight gain in infants and toddlers
Inadequate weight gain when plotted on a
centile chart
Mild FTT – Fall across 2 centile lines
Severe FTT – Fall across 3 centile lines
Illustrated textbook of peadiatrics, 4th edition

DIAGNOSED BY:
Weight that falls or remains below the third
percentile for age
OR
Weight that decreases, crossing two major
percentile lines on the growth chart over
time
OR
Weight that is less than 80% of the median
weight for the height of the child
Nelson, essential of Peadiatrics, 6th edition.

Failure
to
Thrive
INADEQUATE
INTAKE
INADEQUATE
RETENTION
MALABSORPTION
INCREASED
REQUIREMENT
FAILURE TO
UTILISE NUTRIENT

INADEQUATE
INTAKE
ORGANIC
NON-
ORGANIC

Organic
Causes
Impaired
Suck/Swa
llow
Oromotor
Dysfunction
Neurological
Dysfunction eg
Cerebral Palsy Mechanical
feeding
difficulty
Cleft
Palate/cleft lip
Chronic
illness
leading to
anorexia
Crohn’s
Disease
Chronic
Renal
Failure
Illnesses
that
increase
metabolic
demands
Liver
Disease
Organic Causes:
caused by an underlying medical disorder.

Non-organic Causes
Inadequate availability of
food
Feeding Problem—Insufficient breast milk
or poor technique or ineffective latching,
incorrect preparation of formula
Insufficient or unsuitable food
offered
Lack of regular feeding
time
Infant difficult to feed
Conflict over feeding, intolerance of
normal feeding behavior- eg
throwing food around or messiness
Problem with budgeting, shopping,
cooking food, famine
Low socioeconomic status
Psychosocial
Deprivation
Poor maternal-
infant interaction
Maternal
depression
Poor maternal
education
Neglect or Child
Abuse
Factitious
illness
Non-organic Causes:
associated with broad spectrum of psychosocial and environmental
deprivation

• Vomiting
• Severe Gastro esophageal reflux
INADEQUATE
RETENTION
• IDA
• biliary atresia
• Coeliac Disease
• irritable bowel syndrome
• Cystic Fibrosis
• Cow’s milk protein intolerance
• Short Gut Syndrome
• Post Necrotizing Enterocolitis, NEC
MALABSORPTION
• Chromosomal disorders (eg: Down Syndrome)
• IUGR
• Congenital infection
• Metabolic disorder (congenital hypothyroidism, storage disorders,
amino- and organic acid disorder)
FAILURE TO UTILISE
NUTRIENT
• Thyrotoxicosis
• Cystic fibrosis
• Malignancy
• Chronic infection(HIV, Immune deficiency,TB)
• chronic lung disease
• Congenital heart disease
• Chronic renal failure
INCREASED
REQUIREMENT

DEMONSTRATE THE
IMPORTANCE OF A
FEEDING HISTORY

The importance of a feeding
history
• To know the current nutritional intake
• To provide the better look at correlating the
infant’s development with the types of food
offered.
• To assess the adequacy of nutritional intake
for growth.
• To screen for undernutrition or nutritional
deficiency.
• To detect the causes of undernutrition and
exclude other causes of FTT

Feeding history
Breastfeeding
Formula feeding
Weaning
Types of
feeding :

Breastfeeding history
History Comments
1. Ask if the baby is breast
fed or bottled fed
•Full term newborn babies can obtain all the
nutritional needs from breast milk in their first 4-6
months (only breastmilk can supply the secretory
Ig A, lactoferrin, peroxidase, lysozyme).
2. The duration of exclusive
breastfeeding and mixed
breastfeeding
Exclusive breastfeeding reduces infant mortality
due to common childhood illnesses such as
diarrhoea or pneumonia, and helps for a quicker
recovery during illness.
3. Frequency per day Demand or timed
Well term babies should be given breast feed on
demand. (usually 8-12 times/day)
4. Strength of sucking Good sucking reflex means that the baby is well.
Otherwise baby may be too weak to suck.
5. Any difficulty in
breastfeeding
The common reasons to quit breastfeeding are:
 Low milk production
 Mastitis
 Flat or inverted nipples
 Sore nipples

Formula feeding history
History Comments
1. Type of formula Infant, special, soy formula
2. The amount and frequency of milk
intake
 1 oz= 30mls
 The milk requirement
Day 1: 60mls/kg/day
Day 2-3: 90mls/kg/day
Day 4-6: 120mls/kg/day
Day 7 onwards: 150mls/kg/day
3. Preparation of feeds and hygiene Bottle sterilization, water source
4. Who feeds the baby Placement of the infant for feeding

Weaning
History Comments
1. Ask about weaning and
when did the weaning start.
 Food is needed after 6 months of age in addition
to milk to satisfy the increasing energy demands
of the infant.
 However, babies should not be started on foods
other than milk before they are 4 months old as
their kidneys and digestive system are not fully
developed.
2. The types of solid food
introduced
 Normally cereals are introduced and mix with
food such as stewed fruits, mashed banana and
pumpkin.
 Gradually, at around 8 months, an eating pattern
of 3 meals a day should emerge. The type and
quantity of food taken for breakfast, lunch and
dinner should be obtained to quantify total
calorie intake.
3. Ask about the feeding
pattern (Abnormal feeding
pattern can cause
 Refusal (selective to mode of feeding or to a
specific parent or selective for some types of
food)

EXPLAIN THE
PRINCIPLES OF
INFANT NUTRITION

WHO recommends the following:
1. Exclusive breastfeeding for the first six months of life
to achieve optimal growth, development and health
2. Infants should receive nutritionally adequate and safe
complementary foods while breastfeeding continues for
up to two years of age or beyond.
Calorie requirement:
Term infants : 110 kcal/ kg/ day
Preterm infants : 120-140 kcal/ kg/
day

Types of feeding
1. Breastfeeding exclusive (0-6 months)
-Milk of choice
-Term healthy infants should be breast fed asap within the first hour.
- Human Milk Fortifier (HMF)
*add to expressed breast milk in babies < 32 weeks or < 1500g.
1500g.
*give extra calories, vitamins, calcium and phosphate
2. Formula feeding(modified cow’s milk)
- Only be given if there is no supply of breast milk
- Unmodified cow’s milk
*unsuitable
*too much protein and electrolytes
*inadequate iron and vitamins
a)Preterm Formula : for babies born <32 weeks or < 1500g
b)Normal Infant Formula : For babies born >31 weeks or > 1500g
3. Specialised infant formula
- Cow’s milk-based formulas
- Soy formulas
4. Complementary food and weaning

1. Complementary feeding of semisolid food is recommended by
approximately 6 months as exclusively breastfed infants require
additional protein, iron and zinc.
2. Relatively high-fat and calorically dense diet is needed to deliver
adequate calories due to increased activity.
3. General signs of readiness for weaning:
- holds head and sit unassisted
- brings objects to mouth
- shows interest in food
- able to track spoon and open the mouth
4. Examples:
- Vitamin-fortified and iron-fortified dry cereal
- Mixed cereals (oat, corn, wheat and soy) provide greater variety to
older infants
- Juice (in cup and limited to 4 oz daily)
5. Honey should not be given before 1-2 years of age (risk of infantile
Complementary Food and Weaning

DESCRIBE THE
NUTRITIONAL
REQUIREMENTS FOR
CHILDREN

INTRODUCTION
1. Nutrient needs determined by:
 Body size
 Growth rate
 Age
2. A child’s requirement is higher than an
adult’s.
3. Nutritional deﬁciency are more
commonly seen in infancy as young
children have fewer body reserves of all
nutrients.

Source: National Coordinating Committee on Food and Nutrition (2005)

Recommended Nutrient Intake
(RNI)
1. RNI for children do not differ for boys
and girls except for energy.
2. All RNI values has a margin of safety
except for energy
3. RNI for most nutrients is higher than
physiological needs of most children.
4. If nutrient intake of a child less than
RNI, it does not necessarily mean child
has nutritional problem.

Nutrient Recommendations
• Based on Malaysian Dietary Guideline
(MDG) 2010:
Key message 12:
Practice exclusively breastfeeding
from birth until six months and
continue to breastfeed until two
years of age.

Key recommendations:
• Prepare for breastfeeding during pregnancy
• Initiate breastfeeding within one hour of birth
• Breastfeed frequently and on demand
• Give only breast milk to baby below six months with
no additional fluid or food
• Continues to give babies breast milk even if baby is
not with the mother
• Introduce complementary foods to baby beginning at
six months of age
• Lactating mothers should get plenty of rest, adequate
food and drink to maintain health
• Husbands and family members should provide full
support to lactating mothers

Cereal Products and Tubers group

Fish, Poultry, Meat and Egg(2)

FORMULATE THE
APPROACH TO
MANAGEMENT OF A
CHILD WITH FAILURE
TO THRIVE

Calories required for catch-up
• Children with failure to thrive require
150% of Recommended Daily Requirement
of calories
• Schedule: Replacement calories needed
per day for malnourished and catabolic
infant
Age 0-6 months:
130-150 KCal/kg/day (high)
150-220 KCal/kg/day (very high)

ORGANIC FAILURE TO
THRIVE
Treat underlying medical condition
Caloric supplementation
• Depend on severity and underlying medical
problems.
• The responds depends on : (Specific diagnosis,
medical management, severity of the failure to
thrive.)
Monitor amount of protein
• In children with renal failure

NON ORGANIC FAILURE TO
THRIVE
Home visit
- By health visitor
- Assess eating behavior
- Provide support
Direct practical advice
following observation
Paeds dietician
- Assess quantity &
composition of food intake
- Recommend strategies to
increase E intake
Speech & language
therapist
- Feeding disorder therapy
Clinical psychologist &
social services
Nursery placement
- Alleviate stress at home
- Assist feeding

Solid food -> liquid
Environmental distraction minimized
Eat with other people
Not force-fed
Rule of 3 : 3 meals, 3 snacks, 3
choices

Limit intake of :
• water
• juice
• soda
• low-calorie beverages
Emphasize intake of : high-
calorie foods –
• peanut butter (??)
• whole milk
• cheese
• dried foods
High-calorie
supplementation :
• Duocal
• Polycose
High-calorie liquids :
• Carnation Instant
breakfast with whole milk
• Formulas containing
>20cal/oz – Pediasure,
Ensure, Resource

FAILURE_TO_THRIVE3.pptx

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