FAILURE TO THRIVE

1. FAILURE TO THRIVE Sabina A Ali, M.D. Pediatric Gastroenterology February 2008

2. OVERVIEW • Case • Background • Epidemiology • Definitions • Factors • Diagnosis • Evaluations • Treatment • Conclusion • Cases that confuse

3. CASE • 15-month-old girl, born full term, no complications was referred by her primary care for evaluation of poor growth. She had grown adequately for the first 6 postnatal months, but her growth began to plateau after 6 months of age. She had experienced nine ear infections over 9 months, several bouts of "pneumonia," and loose bowel movements and "diarrhea" almost constantly. • Nutritional history included breastfeeding for 2 months, followed by weaning to formula. She was started on rice cereal at 4 months of age and gradually was introduced to a variety of pureed foods. She had been eating some table food for many months. • Family history was noncontributory. The parents were very concerned. The maternal grandmother, who had lived with the family, had cancer and was in hospice care. The mother reported depression because of her own mother’s illness. The parents had separated for several months during the last year, but were back together and doing well. • Physical examination included thin, wispy hair; bilateral serous otitis media; transmitted upper airway rhonchi; and a protuberant abdomen. She was normocephalic, her length was at the 10th percentile, and her weight was below the 3rd percentile . She had very thin extremities.

4. GROWTH CHART INTERVENTION

5. BACKGROUND • Early reference to an infant who "ceased tothrive" can be traced to the initial edition of The Diseases of Infancy and Childhood by L. Emmett Holt in 1897. • Holt equated infantile wasting conditions with malnutrition, although he clearly recognized that this could be associated with a variety of clinical circumstances. • The phrase "fail tothrive" first seems to have appeared in print in 1933 in the 10th edition of that classic text.

6. EPIDEMIOLOGY • Prevalence has been reported as 1-5% of all pediatric referrals to pediatric hospitals • 10-20% of all children who are treated in ambulatory care settings.

7. DEFINITION DEFINING FAILURE TO THRIVE CAN BE DIFFICULT 3rd percentile vs 5th percentile 2 standard deviations, 5th percentile 2.2 standard deviations, 3rd percentile

8. DEFINITION • Is a symptom rather than a disease or diagnosis. • Weight (or weight for height) is more than 2 SD below the mean for age and sex. • A child whose weight curve has crossed downward more than 2 major percentiles. • Calculate z scores (research use).

9. MEASUREMENTS • Measure all three- weight, height and head circumference. • In a child younger than 2 years , the recumbent length rather than the standing height is obtained. • Correct plotting and using correct NCHS graphs is essential – Correct for gestational age until: • 18m for head circumference • 24m for weight • 40m for stature • When all are decreased the incidence of organic disease is about 70%. NCHS (National Center for Health Statistics).

10. NORMAL GROWTH • An understanding of abnormal growth requires a review of normal growth patterns • “Patterns of progression in weight and height that is consistent with the established standards for age”.

11. So, What’s Normal? • Infants should regain their birth weight by 2 weeks (15-30 g per day) • Length: Increases 25 cm in first year • HC averages 35 cm birth to 47 cm at 1 year

12. OTHER DEFINITIONS • WASTED: A decreased weight for age and weight for height with a normal height for age. • STUNTED: A decrease height for age and weight for age with a normal weight for height.

13. Major Anthropologic Categories of FTT. HC: Head Circumference NORM: Normal

14. MIXED ETIOLOGY • 2 BIG categorize but large differential pool. INORGANIC ORGANIC

15. CLASSIFICATIONS • The differential diagnosis of failuretothrive is very broad • Historically, the etiologies of failuretothrive were grouped as organic and nonorganic. • Organic failuretothrive refers to a major disease process or a single or multiple organ dysfunction. • Nonorganic failuretothrive suggests insufficient emotional or physical nurturing without distinct pathophysiologic abnormality. • Some have suggested that there is mixed failuretothrive.

16. CLASSIFICATION More useful classification system is

17. FAILURE TO THRIVE Pulmonary Tonsillar hypertrophy Cystic Fibrosis Renal Chronic pyelonephritis Fanconi syndrome (and variants) Chronic renal insufficiency Endocrine Hypothyroidism Rickets Viitamin D deficiency Vitamin D resistance Central nervous system lesion Hypophosphatemic Growth hormone deficiency/resistance Growth hormone deficiency/resistance Hypercortisolism Pseudohypoparathyroidism Type I diabetes mellitus (poorly controlled, Mauriac syndrome) Central nervous system Pituitary insufficiency Diencephalic syndrome Other chronic diseases Oncologic Psychosocial Nutritional Kwashiorkor Marasmus Zinc/iron deficiency Feeding disorders Oral-motor apraxia Cleft palate Dentitions GI Vomiting Gastroesophageal reflux Structural anomalies Central nervous system lesion Diarrhea Chronic toddler diarrhea Infectious Malabsorption Celiac disease Inflammatory bowel disease Hepatic Chronic hepatitis Glycogen storage diease Infectious Tuberculosis Human immunodeficiency virus Cardiac

18. Calories, Calories,…… • Root of growth failure stems from • inadequate calories • – Inadequate intake • – Increased demands • – Poor absorption • Infants require approximately 110-120 kcal/kg/day At age 1 year, 100 kcal/kg/day

19. CALORIC INTAKE • Inadequate Caloric Intake • Incorrect preparation of formula • Poor feeding habits (ex: too much juice) • Poverty • Mechanical feeding difficulties (reflux, cleft palate, oro-motor dysfunction) • Neglect Consider child abuse and neglect in cases of FTT that don’t respond to appropriate interventions

20. Inadequate absorption • Celiac disease • Cystic fibrosis • Milk allergy • Vitamin deficiency • Biliary Atresia • Necrotizing enterocolitis

21. Increased metabolism • Hyperthyroidism • Chronic infection • Congenital heart disease • Chronic lung disease • Other considerations • Genetic abnormalities, congenital infections, metabolic disorders (storage diseases, amino acid disorders)

22. EVALUATION • Accurately plotting growth charts at every visit. • Use correct growth charts! • Evaluate the trends • History and Physical more important than labs

23. Examination: Key Points • Infant eye contact (if avoids may be abuse) • Poor suck or motor skills • Watch caretaker feed the infant!!! • Plot height, weight and head circumference • Dysmorphic features • Lung or heart exam • Skin: scars, jaundice, eczema, bruises or rash

24. COMPREHENSIVE NUTRITIONAL ASSESMENT • Dietary history • Medical and medication history • Physical examination • Growth and anthropremetric measurements • Laboratory tests.

25. HISTORY • Pregnancy/Birth LBW, IUGR, prematurity, postnatal complications, tube feeding. Substance abuse? postpartum depression? • Dietarytype of food, time spent over meal, number of meals, self feed, formula/supplements, unusual feeding behavior, who feeds? • Past medical history Illnesses, hospitalizations, reflux, vomiting, stools, difficulty swallowing • Social Who lives in the home, family stressors, poverty, drugs? • Family Parental height, siblings, Medical condition (or FTT) in siblings, mental illness, stature?

26. DIETARY HISTORY • Assess methods of feeding • breastfeeding patterns (including maternal diet use of medications that can affect milk production and let-down such as alcohol or diuretics) • formula preparation • volume consumed • feeding techniques. • Caloric counts- food diary • A detailed history of formula preparation :may reveal a dilute formula that contains insufficient calories and excess water.

27. Dietary Associations With Poor Growth in Young Children • Breastfeeding difficulties • Improper formula mixing • Poor transition to food (6 to 12 months of age) • Excessive juice consumption • Avoidance of high-calorie foods

28. INVESTIGATIONS • Lab tests should be guided by H&P. • Less than 2% of the lab studies performed in evaluating children with FTT were useful. Sills RH AM J Dis Child 1978

29. SECOND LINE Serum AA Lead level Ur organic acids LFTs PPD Abd US CXR Head US EKG/Eho FIRST LINE CBC ESR, CRP UA/Cx, Cr, glucose, Ca Thyroid functions Sweat Chloride Celiac serology (age) INVESTIGATIONS HISTORY AND PHYSICAL

30. 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

31. CALORIC REQUIREMENT • To determine caloric requirements for infants : • RDA for age (kcal/kg) x ideal weight for height (kg)/actual weight (kg)

32. INTAKE • 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 (e.g 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

33. WHEN TO HOSPITILIZE • Do you hospitalize? • Rarely necessary • Consider if: • the child has failed output management • FTT is severe • Medical emergency if wt <60-70% of ideal wt • Hypothermia, bradycardia, hypotension • safety is a concern

34. HOSPITILIZATION • For difficult cases: • Multidisciplinary team approach produces better outcomes • Dietitians • Social workers • Occupational therapists • Psychologists • NG tube supplementation may be necessary

35. Hospitalization • In 1988, Frank and Zeisel reported that 3% to 5% of admissions to academic pediatric medical hospitals were for failuretothrive. • At this author’s regional pediatric referral center, 3.9% of inpatient admissions from November 1998 to October 1999 carried failuretothrive as a discharge diagnosis. • Berwick et al demonstrated that the diagnostic yield of hospitalization was not cost-effective. • They found that only 0.8% of all tests demonstrated an abnormality that contributed to an underlying diagnosis. • On their review of the inpatient records of 122 infants who had unexplained failuretothrive by ages 1 to 35 months, approximately 33% had no diagnosis following the evaluation, 32% had a social or environmental etiology, and 31% were given a specific physiologic or organic diagnosis. • Of this latter group, 66% had gastroesophageal reflux or nonspecific diarrhea.

36. HOSPITILIZATION Mainstay of management if the child is refractory to the previously mentioned outpatient procedures. • Hospitalization has little impact (other than increasing costs) on the diagnostic categorization of failuretothrive. • Management may be enhanced during a hospitalization. • Hospitalization of an infant who has failuretothrive allows timely input from important ancillary health-care staff, including nutritionists, social workers, occupational and physical therapists, therapeutic recreation workers ("child life specialists"), behavioral and developmental specialists and psychologists, and bedside nurses. • A hospitalization of 10 to 14 days or greater with adequate caloric intake commonly is believed to be sufficient to demonstrate appropriate weight gain. • Unfortunately, it has become clear in today’s medical environment that third-party payers are reluctant, if not sometimes refusing, to authorize hospitalization for the evaluation and treatment of failuretothrive. • Practitioners scrutinized their diagnostic evaluation of such children or performed key diagnostic studies on an outpatient basis.

37. TAKE HOME POINTS • Evaluation 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. • 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

38. TAKE HOME POINTS • Accurate plotting is essential • Most important evaluation is H&P • Dietary history and social milieu are important clues. • Key is to observe family/infant Interactions. • Selective labs may be useful. • Catch up growth requires increased calories, and there are many ways to achieve this

39. CASE FOLLOW UP • Laboratory studies were ordered and a sweat test scheduled. • The family was asked to feed her three meals and three nutritious snacks on a set daily schedule. • The importance of social support for the family dealing with a sick child, a fragile marriage, and a dying grandmother was discussed, and the family was helped to contact community mental health services. Telephone contact was maintained. • Laboratory studies: showed anemia, a low serum albumin, and positive tests for celiac disease. These positive tests were confirmed by an intestinal biopsy diagnostic for celiac disease. Her sweat test was negative. She responded to a gluten-free diet with excellent weight gain.

40. DIAGNOSED WITH CELIAC DISEASE AND GLUTEN FREE DIET STARTED

41. CASE • In this case, the important psychosocial problems were not the cause of the child’s FTT. • These issues may have delayed her diagnosis by distracting the family from her symptoms or biasing her pediatricians against a medical cause for her poor growth. • On the other hand, she was diagnosed at a young age, and she made an excellent recovery after the proper diet was instituted. • The important clues for an underlying medical condition included the history of recurrent infections, physical findings consistent with severe malnutrition, and a height percentile decreasing nearly simultaneously with the decreasing weight percentile.

42. CONDITIONS THAT CONFUSE WITH FTT Familial Short Stature: Genetically determined Final Height consistent with mid-parental height Child maintains a growth curve appropriate for the family without deviation to a lower percentile. Constitutional growth delay: Usually present with deceleration of growth in the first 2 years of life. Delay in bone age and family history of delayed growth and puberty makes the diagnosis more likely.

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