Dr.Saravanan mahendra FMS Trainee 2012/2013 University Kebangsaan Malaysia

1. Dr.Saravananmahendra FMS Trainee 2012/2013 University Kebangsaan Malaysia

2. Overview • Objective • Definitions • Introduction • Diagnosis • Treatment • Outcome • Approach Short stature • Case presentation • Take Home message

3. Objective • Attain sufficient knowledge and skills to recognize and manage children with problems in nutrition and feeding

4. Definition • Failure to thrive : • Weight below the 3rd or 5 thcentile for age on more than one consecutive occasion • Weight drops down two major percentile lines • Others : • Weight less than 80% of the ideal weight for age • Below 3rd or 5h percentile on the weight for length curve

7. Introduction • FTT is not a diagnosis/syndrome rather a sign that a child is receiving inadequate nutrition for optimal growth and developmental • Usually describes failure to gain weight • In more severe cases length and head circumference can be affected • Causes tend to be multi-factorial and often involve problems with diet and feeding behaviour

8. Specific infant populations- • Premature/IUGR – weight 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 such as Down, Turner and Williams syndrome

9. 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 caloricabsorption • Increased caloric requirements

10. Inadequate Caloric Intake • Not enough food offered • Food insecurity • Poor Knowledge of child's needs • Poor Transition to table food • Avoidance of high calorie foods • Formula dilution • Excessive juice • Breast feeding difficulties • Neglect / Abuse

11. Inadequate Caloric intake…. • Child not taking enough food • Oromotor dysfunction • Developmental Delay • Behavioural Feeding problem • Altered oromotor sensitivity • Pain and conditioned aversion • Emesis • GERD • Malrotation with intermittent volvulus • Increased Intracranial Pressure

12. Inadequate Caloric absorption • Cystic Fibrosis • Celiac Disease • Food Protein insensitivity or intolerance • Cow milk protein allergy • Lactose intolerance

13. Increased Caloric Requirement • Insulin Resistance (ex: IUGR) • Congenital infection (ex: HIV,TORCH) • Syndrome (Down, Russell-silver,,Turneer) • Chronic disease • Cardiac • Renal • endocrine

14. Diagnosis • Accurately plotting appropriate growth charts (WHO / CDC chart ) • < 6 month : Not more than monthly • 6 -12 month : 2 montly • > 12 month ; 3 monthly • At every visit recommended or whenever parents concern arise • Assess the trends • History taking and physical examination are more important than laboratory test • Most cases in primary care setting are psychosocial or nonorganic in etiology

15. Standard growth chart ? • WHO (World Health Organization ) charts: • Standard growth chart which describe how healthy children should grow under optimal condition • Such optimal conditions : • High socioeconomic status • Singleton mothers • Breastfeeding • No smoking • CDC (Central Disease Control) charts • 0-2 years : use WHO growth standards • 2 years + : use CDC growth charts

16. Breastfeeding

17. WHO versus CDC • In the first few months of life • WHO curves show a faster rate of weight gain • Use of the WHO charts • Increase in the misperception of poor growth in formula fed infants • After 3 months • WHO curves show a slower rate of weight gain • Use of the WHO charts • Might identify formula fed infants as gaining weight too quickly

18. History taking… • 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?

19. Physical • Accurate measurement of child’s height, weight, head circumference and plot in the appropriate chart • Evaluate for dysmorphic features • Mouth, palate • Neurologic exam • Signs of spasticity or hypotonia • Cardiovascular/Lung exam

20. Physical • Signs of neglect or abuse • Lack of age appropriate eye contact, smiling, vocalization, or interest in environment • Chronic diaper rash • Impetigo • Poor hygeine • Bruises • Scars

21. 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?

22. Lab Evaluation • Unless suggested by history and physical examination suggestive, no routine lab tests recommended initially : • One study of hospitalized pts resulted in only 1.4% of tests being of diagnostic assistance in FTT

23. Laboratory investigation

24. Management • Goal is catch up or increase 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 help to social welfare and child protector if needed

25. 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

26. 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

27. Management • Hospitalization ? • Rarely necessary • Consider if: • the child has failed outpatient management • FTT is severe • Medical emergency if wt <60-70% of ideal wt • Hypothermia, bradycardia, hypotension • safety is a concern (neglect / abuse )

28. What is Z score or standard deviation score? • Z-score (or SD-score) = (observed value - median value of the reference population) / standard deviation value of reference population • The expected ranges of standard deviations of the Z-score distributions for the three anthropometric indicators are as follows (5): • height-for-age Z-score: 1.10 to 1.30 • weight-for-age Z-score: 1.00 to 1.20 • weight-for-height Z-score: 0.85 to 1.10 • The WHO Global Database on Child Growth and Malnutrition uses a Z-score cut-off point of • <-2 SD to classify low weight-for-age, low height-for-age and low weight-for-height as moderate and severe under nutrition • <-3 SD to define severe under nutrition. • >+2 SD classifies high weight-for-height as overweight in children

31. Management • For difficult cases: • Multidisciplinary team approach produces better outcomes • Dietitians • Social workers • Occupational therapists • Psychologists • NG tube supplementation may be necessary • For organic causes treat the underlying illness

33. 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

34. 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

35. 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

36. Approach to Short Stature

37. Case Presentation..Question 1 • KP, a 3 years old girl was brought by parents to the clinic because of her weight. She was born full term with a birth weight of 3.1kg. She was on Infant formula milk since birth. She was changed to full cream milk since 2 years, supplemented with Enercal as recommended by a health professional because of her weight problem. She started weaning at the age of 6 months.ntroduced to her diet since six months. Protein intake was adequate in spite of her small appetite. • Her father measured 160.5cm (3-10thcentile), weighed 70kg (75-90thcentile) and mother measured 143.9cm (2.6S.D), weighed 38kg (2 kg below 3rdcentile) • At 3.2 years, KP measured 84.5cm ( -2.5 S.D), weighed 10.6kg. By 7.6 years she measured 106.4cm ( -2.8 S.D), weighed 15.3kg (1.7 kg below 3rdcentile). Below are the illustrate chart. Please comment this scenario

38. Comment : KP parents mid parental height (MPH) measured :(( Father height-13) + Mothers height ) /2= 143.5 cm. Her MPH is at below 3rdcentile of the height percentile.Meanwhile KP height and weight at 3.2 years is below the 3rdcentile. However as she grows her subsequent measurement at 7.6 years shows that her height and weight is increasing proportionately. Her height is growing appropriately corresponding her Mid Parental height which is below the 3rdcentile as well. In summary : KP is familial constitutional small size girl who is growing according to her genetic growth potential.

39. Case Presentation.. Question 2 • CPY was born full term with birth weight of 3.5kg. Her subsequent were as shown in chart 2. Between the period of 4 and 13month, she had recurrent coughs and colds along with a long period of poor dietary intake. She more or less fully recovered from her illness after 14months  • What does this below chart illustrate?

40. CPY chart shows initially good growth weight at birth till 4 month old. However her weight gain goes downtrend crossing the 2 centile line and reaching below 3rdcentile at the age of 14 month. This suggest as Failure to thrive secondary to chronic lung disease which causes inadequate nutritional intake. Once CPY recovered from her illness and start to resume normal feeding, her weight gain increase drastically

41. Take Home Message • Evaluation of Failure to Thrive involves careful history taking and physical examination, 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.

42. Take Home Message • 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