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Failure to Thrive

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Failure to Thrive

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    1. Failure to Thrive Joyee G. Vachani, MD April 21st, 2010

    5. Definition <3rd or 5th percentile on growth chart Change in growth that has crossed two %s Gomez criteria: compare current wt for age with expected weight for age (at 50th %) weight <60% of expected = severe FTT 61-75% = moderate FTT 76-90% = mild FTT

    6. Growth charts Look at trends over time Use appropriate growth charts Premies: corrected age on term growth charts Trisomy 21 Weight decreases first ? Length Low wt only: acute undernutrition Low wt and ht: chronic malnutrion/stunting Low wt, ht, and HC: Congenital or genetic abnormalities Severe malnutrition

    7. Normal weight gain - 26 to 31 g/day for those 0 to 3 months - 17 to 18 g/day for those 3 to 6 months - 12 to 13 g/day for those 6 to 9 months - 9 to 13 g/day for those 9 to 12 months - 7 to 9 g/day for those 1 to 3 years

    8. Growth Chart quiz http://emedicine.medscape.com/article/985007-media

    9. Your patient You are about to see a patient admitted to FIS for Failure to Thrive… where do you start?

    10. History Dietary Hx Psychosocial Hx Birth Hx Family Hx ROS Development Recurrent infections GI hx Resp hx

    11. History Dietary Hx: quantify caloric intake Foods and Formula: prep, frequency Juice and water intake Behaviors at mealtime Psychosocial Hx Pregnancy Hx Parent mental health and intellectual capacity Birth Hx Family Hx Systemic disease: IBD, asthma, CF FTT Short stature ROS Development Recurrent infections GI hx: vomiting, GER, stool: diarrhea, pattern, frequency, consistency, NBNM Resp hx: chronic cough, SOB, snoring

    12. Physical Exam www.cdc.gov/growthcharts Dymorphic features OP: clefts, suck, caries Chest, Abd, Neuro Skin: loose skin = muscle wastage Edema = protein deficiency Observe interaction between parent and child

    13. Back to your patient You have completed your H+P and are formulating an assessment and plan… What are your next steps?

    14. Labs Minimal, if any, labs if a proper H+P is done! Screening tests CBC, ESR, CMP, UA and Urine Cx Stool: fat, cx Sweat test Other possible tests Igs, TFTs, Fe/Lead PPD, HIV UOA, Karyotype Bone Age CBC (anemia or malignancy) ESR CMP (metabolic disorders, renal disorders, liver disease, electrolyte abnormalities for refeeding) UA and Urine Cx (UTI, RTA) CBC (anemia or malignancy) ESR CMP (metabolic disorders, renal disorders, liver disease, electrolyte abnormalities for refeeding) UA and Urine Cx (UTI, RTA)

    15. Labs Not much use if a proper H+P is done! Screening tests CBC, ESR, CMP, UA and Urine Cx CBC (anemia or malignancy) ESR CMP (metabolic disorders, renal disorders, liver disease, electrolyte abnormalities for refeeding) UA and Urine Cx (UTI, RTA) Stool: fat, cx Sweat test Other possible tests Igs, TFTs, Fe/Lead PPD, HIV UOA, Karyotype Bone Age Familial short stature: bone age = chronological age Endocrine/Nutritional abnormalities: bone age<chron age

    16. DDx: it’s all about the calories Inadequate caloric intake (most common) Inadequate caloric absorption/utilization Increased caloric requirements (ie. excess metabolic demand) Physiologic causes that are not FTT Prematurity Familial short stature Constitutional growth delay SGA

    17. Inadequate Caloric intake Inappropriate volume or type of food Incorrect formula preparation Excess juice or water Poor feeding technique Oromotor dysfunction or cleft palate Psychosocial

    18. Inadequate caloric absorption/utilization Vomiting GERD Obstruction Increased ICP, meds, illnesses – UTI, metabolic disorders (storage diseases, amino acid disorders) IBD, CF, Celiac disease, Short gut MPA, Lactose intolerance, Allergic colitis Liver disease Vitamin or mineral deficiencies

    19. Increased caloric requirements (? met Demand) Cardiac disease Chronic lung disease Endocrine disorders – DM, DI, hyperthyroid, adrenal/pituitary disease Anemia, Hgb SS, Thalassemia Genetic/chromosomal abnormalities (Tri 21) Any chronic disease

    20. Treatment Catch up growth 10 days to 1 month 120 kcal/kg/day 1-2 months 115 kcal/kg/day 2-3 months 105 kcal/kg/day 3-6 months 95 kcal/kg/day 6 months to 5 yrs 90 kcal/kg/day Vitamin and mineral supplementation Fe and Zinc Monitor for refeeding

    21. When do you admit? Most cases of FTT can be managed outpatient Admit Severe FTT/Malnutrition Moderate dehydration Infection Further diagnostic and laboratory evaluation Lack of catch-up growth Evaluation of parent-child feeding interaction

    22. When do you discharge? Adequate, consistent weight gain demonstrated Diagnostic tests and consultations complete Proper follow-up arranged The caretaker demonstrates understanding of nutrition recommendations and growth expectations

    23. Prognosis FTT in 1st year of life (regardless of cause) is particularly ominous Maximal brain growth occurs in first 6 months of life 1/3 children with psychosocial FTT are developmentally delayed and have social and emotional problems

    24. *prematurity, SGA, TORCH, etc.*prematurity, SGA, TORCH, etc.

    27. PREP Question #1 You are evaluating a 6 month old child who has a VSD and is scheduled for cardiac surgery. The child’s weight is 6 kg (3rd%), length is 30th%, and HC is 50th%. His mother states she prepares the formula by adding 1 scoop of powder to 2 oz water. She estimates that he drinks 24 oz of formula per day. You estimate the baby’s intake is approx 500 kcal per day of cow milk formula, which is the RDA for his age. According to his mother, he spits up three times per day and passes two soft stools daily. On physical exam, you hear a 3/6 holosystolic murmur and palpate the liver 1 cm below the RCM.

    28. PREP Question #1 cont… Of the following, the BEST explanation for the child’s malnutrition is: A. Caloric requirement exceeding RDA  B. Cow milk protein intolerance C. Incorrect preparation D. Pathologic gastro-esophageal reflux E. Undiagnosed pancreatic insufficiency  

    29. PREP Question #1 cont… Of the following, the BEST explanation for the child’s malnutrition is: A. Caloric requirement exceeding RDA  B. Cow milk protein intolerance C. Incorrect preparation D. Pathologic gastro-esophageal reflux E. Undiagnosed pancreatic insufficiency  

    30. PREP Question #1 ANSWER A. Caloric requirement exceeding RDA The child in this scenario has a large VSD – a chronic illness which increases his metabolic demand and therefore caloric requirements (RDA).

    31. PREP Question #2 During the health supervision visit of a 2-week-old infant, you note that his weight remains below his birthweight. The baby was delivered by a midwife in the parents’ home. There were no complications, and the parents have declined all perinatal testing. His mother says he breastfeeds well, and her milk supply is good compared with that for her previous two children. Recently, though, the infant has been vomiting after feedings. On physical examination, he has total body jaundice, and his liver is enlarged to palpation. He is alert.

    32. Prep question #2 cont… Of the following, the test that is MOST likely to aid in diagnosis is: A. Abdominal ultrasound  B. Serum transaminases measurement C. Total/direct bilirubin D. Urine organic acid measurement E. Urine reducing substance measurement

    33. Prep question #2 cont… Of the following, the test that is MOST likely to aid in diagnosis is: A. Abdominal ultrasound  B. Serum transaminases measurement C. Total/direct bilirubin D. Urine organic acid measurement E. Urine reducing substance measurement

    34. Prep question #2 answer E. Urine reducing substance measurement The child in this scenario has findings suggestive of classic galactosemia: within days of initiation of milk feedings, the infant has vomiting, then develops hepatomegaly, and FTT. Galactosemia results in the inability to oxidize galactose and the accumulation of galactose in organs such as the liver, kidneys, brain, and eyes. Galactose is a urine reducing substance.

    35. SUMMARY/Pearls DDx for FTT – think calories! ? Caloric intake (most common) ? Caloric absorption/utilization ? Caloric requirements (? metabolic demand) A systematic approach to H+P often leads to diagnosis Detailed feeding hx is especially key Labs should be minimal and guided by H+P Children with FTT need solid follow-up to follow weight and developmental progression

    36. References 2009 PREP Self-Assessment. http://emedicine.medscape.com/article/985007-media Kliegman: Nelson Textbook of Pediatrics, 18th ed. Chapter 37 – Failure to Thrive. 2007. Olsson, JM. Failure to Thrive. Pediatric Hospital Medicine. 2nd edition. 2008: 97-100. Stewart, CS. Failure To Thrive. The 5 Minute Pediatric Consult. 5th edition. Ed Schwartz, MW. 2008: 318-319.

    37. Thank you! ? “You know you’re a pediatric hospitalist when… ...you've got the art of inpatient FTT down to an amazing, precise science: Give it milk. Watch it grow.” From the AAP Hospitalist Medicine Listserve Gregory Plemmons, MD

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