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1. Pediatric Failure to Thrive Michael Michener, MD
Major, USAF
14 March 2007
2. Overview Definitions
Case presentation
Introduction
Diagnosis
Treatment
Outcomes
Top 6 things to remember about FTT
3. Definition Failure to Thrive (FTT):
Weight below the 5th percentile for age and sex
Weight for age curve falls across two major percentile lines
Other definitions exist, but are not superior in predicting problems or long term outcomes
4. Case Presentation 4 mo F, well child visit (Sept 06)
Mom complained about poor wt gain
Same problem with first child
Husband deployed
Parents small stature
Other development was normal
Mom alleged that feeding was going well (breastfeeding)
Wt = 10 lb 8 oz
5. Case Presentation Went to ER at age 5 months
Wt was “down 1 lb”
Infant transferred to a childrens hospital for inpatient stay
Infant refusing to breast or bottle feed
NG tube placed
4oz q4 hours
OT working with baby to help with feeding
6. Introduction Failure to thrive (FTT):
A sign that describes a problem rather than a diagnosis
Usually describes failure to gain wt
In more severe cases length and head circumference can be affected
Underlying cause is insufficient usable nutrition to meet the demands for growth
Approximately 25% of normal children will have a shift down in their wt curve of up to 25%, then follow a normal curve -- this is not failure to thrive
7. Introduction Specific infant populations-
Premature/IUGR – wt may be less than 5th percentile, but if following the growth curve and normal interval growth then FTT should not be diagnosed
Modified growth charts exist for specific populations
8. Introduction Historically has been divided into organic and nonorganic causes
Most cases have mixed etiologies
This classification system is out of favor
More useful classification system is:
Inadequate caloric intake
Inadequate fat or carbohydrate absorption
Increased energy requirements
9. Etiology Inadequate Caloric Intake
Incorrect preparation of formula
Poor feeding habits (ex: too much juice)
Poverty
Mechanical feeding difficulties (reflux, cleft palate, oromotor dysfunction)
Neglect
Physicians are strongly encouraged to consider child abuse and neglect in cases of FTT that don’t respond to appropriate interventions*
10. Etiology Inadequate absorption
Celiac disease
Cystic fibrosis
Milk allergy
Vitamin deficiency
Biliary Atresia
Necrotizing enterocolitis
11. Etiology Increased metabolism
Hyperthyroidism
Chronic infection
Congenital heart disease
Chronic lung disease
Other considerations
Genetic abnormalities, congenital infections, metabolic disorders (storage diseases, amino acid disorders)
12. Diagnosis Accurately plotting growth charts at every visit is recommended*
Assess the trends
H&P more important than labs
Most cases in primary care setting are psychosocial or nonorganic in etiology
*(SOR – C, expert and consensus opinion, Ref 1)
13. History Dietary
Keep a food diary
If formula fed, is it being prepared correctly?
When, where, with whom does the child eat?
PMH
Illnesses, hospitalizations, reflux, vomiting, stools?
Social
Who lives in the home, family stressors, poverty, drugs?
Family
Medical condition (or FTT) in siblings, mental illness, stature?
Pregnancy/Birth
Substance abuse? postpartum depression?
14. Physical Accurate measurement of child’s height, weight, head circumference
Single data point has limited usefulness
Evaluate for dysmorphic features
Mouth, palate
Neurologic exam
Signs of spasticity or hypotonia
Cardiovascular/Lung exam
15. Physical Signs of neglect or abuse
Lack of age appropriate eye contact, smiling, vocalization, or interest in environment
Chronic diaper rash
Impetigo
Flat occiput
Poor hygeine
Bruises
Scars
16. Physical Observe parent-child interactions
Especially during a feeding session
How is food or formula prepared?
Oral motor or swallowing difficulty?
Is adequate time allowed for feeding?
Do they cuddle the infant during feeds?
Is TV or anything else causing a distraction?
17. Lab Evaluation Unless suggested by H&P, no routine lab tests recommended initially*
One study of hospitalized pts resulted in only 1.4% of tests being of diagnostic assistance in FTT
If problem persists, could consider:
CBC, U/A, Electrolytes, TSH, ESR, Lead, HIV, Tb
If not improving with adequate diet, consider:
Stool for fat, reducing substances, pathogens
Celiac antibody testing
CF testing
*(SOR – B, historical, uncontrolled study, Ref 1, 2)
18. Management Goal is “catch-up” weight gain
Most cases can be managed with nutrition intervention and/or feeding behavior modification
General principles:
High Calorie Diet
Close Follow-up
Keep a prospective feeding diary-72 hour
Assure access to WIC, food programs, other community resources
19. Management Energy intake should be 50% greater than the basal caloric requirement
Concentrate formula, add rice cereal to pureed foods
Add taste pleasing fats to diet (cheese, peanut butter, ice cream)
High calorie milk drinks (Pediasure has 30 cal/oz vs 19 cal per oz in whole milk)
Multivitamin with iron and zinc
Limit fruit juice to 8-12 oz per day
20. Management Parental behavior
May need reassurance to help with their own anxiety
Encourage, but don’t force, child to eat
Make meals pleasant, regular times, don’t rush
May need to schedule meals every 2-3 hours
Make the child comfortable
Encourage some variety and cover the basic food groups
Snacks between meals
21. Management Do you hospitalize?
Rarely necessary
Consider if:
the child has failed outpt management
FTT is severe
Medical emergency if wt <60-70% of ideal wt
Hypothermia, bradycardia, hypotension
safety is a concern
22. Management For difficult cases:
Multidisciplinary team approach produces better outcomes
Dietitians
Social workers
Occupational therapists
Psychologists
NG tube supplementation may be necessary
23. Outcomes and Prognosis
Persistent disorders of growth
6 of 7 studies showed statistically significant persistent poor growth (ht, wt, hc) in FTT group at up to 5 years from initial treatment.
Earlier intervention leads to better outcomes
24. Outcomes and Prognosis FTT and Immunologic/Infectious Outcomes
FTT children have significantly increased susceptibility to infection
Among hospitalized children – increased rates of bacteremia and mortality
Increased rates of upper and lower respiratory infections
25. Outcomes and Prognosis Concurrent Behavior disorders
FTT groups scored lower on reports describing affect and communications skills
Behavior disorders at follow-up
Various trials have demonstrated significant increase in behavioral problems
Cognitive Development
There is a consistent association between FTT and lower cognitive development test scores in preschool and primary school children
26. Top 6 take home points Evaluation of Failure to Thrive involves careful H&P, observation of feeding session, and should not include routine lab or other diagnostic testing
Nutritional deprivation in the infant and toddler age group can have permanent effects on growth and brain development
Treatment can usually occur by the primary care physician in the outpatient setting.
27. Top 6 take home points Psychosocial problems predominate as the causes of FTT in the outpatient setting
Treatment goal is to increase energy intake to 1.5 times the basal requirement
Earlier intervention may make it easier to break difficult behavior patterns and reduce sequelae from malnutrition
28. Case Presentation—Follow-up Received NG tube feeds for approx 2 weeks
OT worked with pt to find a nipple that she would take
Wt gain rapidly picked up in late November
29. References Block RW, Krebs NF. Failure to thrive as a manifestation of child neglect. Pediatrics 2005 Nov; 116(5):1234-7. From National Guidline Clearinghouse – www.guideline.gov
Kirkland, RT. Failure to thrive in children under the age of two. Up to Date: http://www.utdol.com/utd/content/topic.do?topicKey=gen_pedi/2884&type=P&selectedTitle=6~29 version 14.2, april 2006:pgs 1-8.
Krugman SD, Dubowitz H. Failure to thrive. American Family Physician, sept 1 2003. Vol 68 (5).
Kane, ML. Pediatric Failure to Thrive. Clinics in Family Practice. Vol 5, #2, June 2003, pages 293-311.
Agency for Healthcare Research and Quality (AHRQ); Evidence report: Criteria for Determining Disability in Infants and Children: Failure to thrive. #72, pages 1-54. http://www.ahrq.gov/clinic/
Bauchner, H. Failure to thrive, in Behrman: Nelson Textbook of Pediatrics, 17th ed, chapter 35, 36 - 2004.
Rudolf M, Logan S. What is the long term outcome for children who fail to thrive? A systematic review. In Arch Dis Child 2005;90;925-931.