This document discusses failure to thrive (FTT) in infants and children. It defines FTT and describes the three main types - Type I, II, and III - based on patterns of weight, height, and head circumference growth. Type I is characterized by weight loss and normal height/head growth, usually due to inadequate calorie intake. Type II shows reduced weight and height growth, often involving endocrine issues. Type III exhibits reduced growth in all areas, commonly stemming from prenatal factors. Nutritional support options and potential complications are also outlined.

2.  definition of FTT.
 Types of FTT.
 Types of nutritional support.
 enteral VS parenetal.
 complications of nutritional support.

3.  is defined as the inability to maintain the expected rate of
growth over time.
 Growth is assessed by plotting the patient's growth
parameters over subsequent visits and comparing the growth
rate to normal population growth rates for age. One set of
measurements can not assess rate of growth and therefore is
not sufficient to diagnose failure to thrive.
 Failure to Thrive (FTT):
› Weight below the 5th percentile for age and sex
› Weight for age curve falls across two major percentile lines

4.  Failure to thrive can be subcategorized into three
types based on the growth patterns of weight,
height, and head circumference. Dividing failure
to thrive into these three types is very helpful
because the differential diagnosis is vastly different
between the three types.

5.  Type I failure to thrive is characterized by the
following growth pattern:
 weight: growth rate significantly reduced or even
weight loss
 height: normal rate of growth or only minimally
reduced
 head circumference: normal rate of growth

6.  The growth chart below depicts the pattern
typically seen in type I failure to thrive.

7.  The majority of patients with failure to thrive have type I failure
to thrive in which there is an imbalance between the
availability of calories and the caloric requirements of the
patient. This can occur for three reasons:
1.inadequate intake of calories
2.excess losses of calories (vomiting or diarrhea/malabsorption)
3.increased caloric requirements (for example,
with hyperthyroidism or diencephalic tumor).
 Inadequate caloric intake and/or excessive losses (usually
secondary to GE reflux) are by far the most common causes
of type I failure to thrive (and failure to thrive in general).
 Patients with type I failure to thrive are referred to as being
"wasted", meaning that they are underweight for their height
(evidenced by a low weight:length ratio or low BMI). This is in
contrast to patients with type II failure to thrive who are
characteristically "stunted"

8.  Type II failure to thrive is characterized by the
following growth pattern
 weight: growth rate significantly reduced or even
weight loss
 height: growth rate significantly reduced (in
proportion to weight)
 head circumference: normal rate of growth

9.  The growth chart below depicts the pattern
typically seen in type II failure to thrive

10.  When you see a patient with this growth pattern, you should
think about an endocrine etiology, as these patients actually
have short stature. The most common causes are:
 familial short stature
 constitutional growth delay
 hypothyroidism, growth hormone deficiency, hypopituitarism
 Patients with constitutional growth delay or familial short
stature typically resume a normal growth velocity after
crossing the 3rd percentile. This results in growth curves that
are parallel to the 3rd percentile. Patients with
hypothyroidism, growth hormone deficiency, or
hypopituitarism typically continue to grow at a suboptimal
rate, with growth curves that continue to fall further below the
3rd percentile.

11.  Patients with type II failure to thrive are referred to as being
"stunted" meaning that their height for age is decreased,
often in proportion to weight. Therefore, these patients have
a normal weight:length ratio or BMI.
 Because this type of failure to thrive is usually not a result of
insufficient caloric intake, nutritional rehabilitation is typically
not benefical. The exception to this is when stunting is
secondary to chronic malnutrition. Chronic malnutrition can
result in stunting, but this usually only occurs after months of
malnutrition. In these patients, the decrease in weight
velocity precedes the decrease in height velocity (they begin
with wasting and progress to stunting). Provision of adequate
calories can result in increased weight velocity followed by
increased height velocity with catch-up growth

12.  Type III failure to thrive is characterized by the
following growth pattern:
 weight: growth rate significantly reduced or even
weight loss
 height: growth rate significantly reduced (in
proportion to weight)
 head circumference: growth rate significantly
reduced.

13.  The growth chart below depicts the pattern typically
seen in type III failure to thrive.

14.  This growth pattern often begins at birth (symmetric
IUGR) and usually results from:
1. intrauterine infections
2. chromosomal abnormalities
3. prenatal exposure to toxins
 These patients often appear dysmorphic or have CNS
abnormalities.
 These patients, like those with type II failure to thrive,
are typically stunted with a normal weight:length ratio
or BMI. Because this type of failure to thrive is usually
not a result of insufficient caloric intake, nutritional
rehabilitation is not beneficial unless wasting is
present.

15.  When managing patients who are malnourished, or who are
at risk to become malnourished, nutritional therapy must be
initiated and monitored closely over time. The goal
of therapy is to provide the calories, protein, vitamins, and
minerals that are necessary to restore or maintain normal
nutritional status.
 Developing a nutritional rehabilitation plan is a complex
process. Some key factors to keep in mind when developing
a nutritional rehabilitation plan are discussed next.

16.  Once you have decided to provide nutritional support, you must
decide the route in which you will provide this support. Although
the decision of enteral vs. parenteral nutrition may seem difficult,
it is actually quite simple. Parenteral nutrition should be used
when, and only when, enteral support is not possible or not
adequate to meet the nutritional needs of the patient.
 Enteral feeding is generally preferred to parenteral nutrition
because it is:
1. more physiologic (provides stimulation of the gut)
2. more economical
3. safer (decreased risk of electrolyte disturbances, infection, and
liver dysfunction)

17.  Occasionally a combination of enteral and parenteral support
is necessary to meet the nutritional needs of the patient.
 In this situation, the maximal amount of enteral support possible
should be used, with the remainder of nutritional
support provided parenterally.
 The main symptoms of feeding intolerance which limit the
ability to feed enterally are:
 vomiting
 diarrhea
 abdominal distension or discomfort

18.  When providing enteral support, one should use the most
physiologic method tolerable to the patient. The feeding regimen
should resemble a normal eating pattern as much as possible.
 Methods of enteral support from most physiologic to least
physiologic are listed below:
1. increased-calorie foods or increased caloric density of infant
formula
2. supplementing the diet with oral nutritional drinks like Pediasure
or Boost
3. gastric bolus feedings
4. gastric continuous feedings
5. jejunal continuous feedings
 Gastric continuous feedings should be used when the volumes
required for bolus feedings are not tolerated by the patient.
 Jejunal feedings are reserved for patients with severely delayed
gastric emptying, severe GER, and patients at risk for
aspiration. Jejunal feedings must be given as a continuous drip, as
the reservoir function of the stomach is bypassed.

19.  The method of supplying enteral support should be
reassessed on a regular basis. The goal in patients who
are receiving gastric or jejunal feeds is to transition back
to a more physiologic method of feeding. Patients who
have a feeding tube in place often receive a portion of
their nutrition orally and a portion of their nutrition through
the tube. Typically the patient is allowed to feed orally
first, and the remainder of the volume goal is given via the
tube. This may be referred to as "nipple-gavage"
feeding. Over time, the goal is to transition the patient
completely back to oral feedings if possible.
 NG or NJ tubes should be used when the course of
therapy is not expected to exceed 1-3 months. Surgical
placement of feeding tubes should be strongly considered
in patients who are expected to require long term tube
feeding.

20.  As previously mentioned, the refeeding syndrome
is a serious complication of nutritional
rehabilitation. Slow progression to the caloric goal
and careful monitoring for and treatment of
electrolyte abnormalities can prevent life-
threatening events. This complication can be seen
with either enteral or parenteral therapy; however,
some complications are unique to either enteral or
parenteral therapy

21. 1. tubemalposition.
For example, an NG tube may be misplaced
and go into the airway. This can result in the infusion
of formula into the lungs, which of course can be
disastrous. Another example of tube malpositioning
is an NG tube that traverses the pylorus and delivers
bolus feedings to the small intestine. This can result
in dumping syndrome and/or abdominal
discomfort. Confirmation of tube position should be
done prior to using any newly placed feeding tube
or if clinical symptoms suggest tube
malposition. This can be done by auscultation, pH
testing for gastric acid, or radiographically.
2. irritation of the tube site (can be seen with nasal
tubes or surgically placed tubes)
3. infection of the tube site (most often seen with
surgically placed tubes).

22.  Parenteral nutrition has a variety of complications
associated with it. The three main categories are:
1. infectious: catheter-related sepsis is a significant
risk with parenteral nutrition and can be life-
threatening
2. metabolic: electrolyte abnormalities, hypo- or
hyperglycemia, cholestasis
3. mechanical: complications with line insertion,
occluded or misplaced lines

23.  http://edactic.medlib.iupui.edu/QMachi
ne.ASP?UID=1O10WXGB&PageId=8&Sess
=726824286

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