Failure to Thrive

1. Failure to Thrive When Simple and Natural Gets Complicated

2. “I’m a Failure to Mother” • Be careful of pejorative language – Parental Deprivation Syndrome (1960) • Primary need is to instill confidence in the family

3. “I’m a Failure to Mother” • “Growth Deficiency” • Weight based assessment • Insufficient growth velocity • Weight • Height • Head Circumference • Organic/Inorganic

4. Start at the Beginning • Uteroplacental Insufficiency • Maternal Hypertension • Diabetes Mellitus • Renal Disease • Collagen Vascular Disease • Genetics • Parental - Age • Fetal – Trisomy, Russell-Silver Syndrome • Maternal Nutrition - time dependant, relatively resistant

5. Start at the Beginning 40% of Growth Deficient infants are born with birth weights of less than 2500 grams (5 pounds 8 ounces)

6. Start at the Beginning During fetal period, endocrine system has little impact on growth. Pituitary aplasia, congenital hypopituitarism or growth hormone insensitivity will have NORMAL weight at birth

7. Normal Growth Variation • More than half of newborns experience an upward shift of growth during the first 3 months • 30% of normal babies experience a downward shift between the ages of 3 and 18 months • Children reach genetic length by 2 years • Many children have significant weight decrease around between 9 and 15 months

8. Timing of Abnormality Severe Anatomic Abnormality Infection – GBS, TORCH Severe Reflux Protein Sensitivity Deprivation Heavy Metal Poisoning Breast Feeding Dysfunction Cardiac Anomaly Chronic Reflux Cystic Fibrosis Milder Anatomic Abnormality Inappropriate Diet Birth 1 week 2-4 weeks 1 month 6 months 9 months 1 year

9. Causes of Failure to Thrive Inadequate Input Increased Utilization Excessive Output

10. Humans are a Closed Energy System CALORIES IN - METABOLIC USE - CALORIES LOST/ NOT USED = ZERO text

11. Causes of Failure to Thrive Inadequate Input Increased Utilization Excessive Output

12. Inadequate Input • INSUFFICIENT NUTRITION OFFERED • MATERNAL/CHILD AXIS DYSFUNCTION • PSYCHOSOCIAL DYSFUNCTION • SEVERE GASTROESOPHAGEAL REFLUX / VOMITING • MECHANICAL PROBLEMS • SUCKING OR SWALLOW DYSFUNCTION

13. Inadequate Input • INSUFFICIENT NUTRITION OFFERED • Maternal Medical Stress • Anti-histamines • Narcotics/Alcohol • Inappropriate or incorrectly constituted formula • Displacement of nutritious offering by poor nutritional component • Vitamin deficiency • Lead (5-35 mcg/dL) potentiated by poor Calcium and Vitamin D

14. Inadequate Input MATERNAL/CHILD AXIS DYSFUNCTION Inappropriate knowledge of infant/child diet Sub-optimal feeding technique Maternal depression Poor bonding (NICU, illness, maternal aversion, abuse)

15. Inadequate Input • PSYCHOSOCIAL DYSFUNCTION • 25% of children in Tennessee live below the poverty level • In Chattanooga 80% of African-American children are born to single mothers (poor social network)

16. Inadequate Input • PSYCHOSOCIAL DYSFUNCTION • Marital stress • Domestic violence • Parental employment • Children of mother’s under 18 have poorer growth and twice as likely to be abused • Number and age of siblings/health of others in the family • Homelessness or home instability/unstable transportation

17. Inadequate Input • SEVERE GASTROESOPHAGEAL REFLUX • Poor intake • Pain feedback loop • VOMITING • Infectious gastroenteritis/post-vial ileus • Chronic pyelonephritis • Increased intracranial pressure • Cyclic vomiting • Poorly controlled Abdominal migraines • Adrenal insufficiency • Ipecac

18. Inadequate Input • MECHANICAL PROBLEMS • Cleft palette • Micognathia or Macroglosia • Tight labial frenulum • Nasal obstruction • Intestinal Obstruction (Volvulus, Intusception, Hirschsprung’s, Pyloric Stenosis) • Chronic constipation • Adenoidal hypertrophy • Dental lesions

19. Inadequate Input • SUCKING OR SWALLOW DYSFUNCTION • Neonatal Abstinence Syndrome • CNS pathology (stroke, tumor, hydrocephalus) • Genetics Syndromes (Trisomy) • Cardiopulmonary Disease • Neuromuscular weakness/tone • Cerebral Palsy • Anorexia of chromic infection, immune deficiency, lead • Behavioral (apathy or rumination)

20. Causes of Failure to Thrive Inadequate Input Increased Utilization Excessive Output

21. Increased Utilization CARDIAC DISEASE Congenital or Acquired SEPSIS CHRONIC RESPIRATORY INSUFFICIENCY Bronchopulmonary dysplasia Cystic fibrosis RENAL DISEASE partial posterior valves, severe reflux with UTI, Renal Tubular Acidosis HYPERTHYROIDISM

22. Increased Utilization • CHRONIC/RECURRENT • SYSTEMIC INFECTION • UTI, Tuberculosis, TORCH • HIV – degree of viremia • correlates with poor growth • MALIGNANCY • INFLAMMATORY BOWEL DISEASE • DIABETES MELLITUS • CHRONIC SYSTEMIC DISEASE • Juvenile Idiopathic Arthritis

23. Increased Utilization • Metabolic Disease • Inborn errors of metabolism • (normal infant that • deteriorates with lethargy, • poor feeding, convulsions, • vomiting) • Storage diseases • Hypercalcemia • Adrenal insufficiency

24. Causes of Failure to Thrive Inadequate Input Increased Utilization Excessive Output

25. Excessive Output • Biliary Atresia • Necrotizing Enterocolitis or Short Bowel Syndrome • Malabsorption • Lactose intolerance Cystic fibrosis • Cardiac disease Inflammatory bowel disease • Milk/food allergy or irritation Parasites • Cystic Fibrosis Celiac Disease • Infectious diarrhea • Renal losses • Fanconi Syndrome Chronic renal insufficiency • Vitamin D resistance Type I Diabetes Mellitus

26. Causes of Failure to Thrive Inadequate Input Increased Utilization Excessive Output

27. Isolated Linear Growth Deficiency Isolated Linear Growth Deficiency • Endocrine Dysfunction • Pituitary Insufficiency • Hypothyroidism • GH deficiency/resistance • Younger children • Hypophosphatemic Rickets • Older children • Hypercortisolism • Pseudohypo- parathyroidism • Familial Intrinsic Short Stature • Chromosomal Abnormality • Trisomy 13, 18, 21 • Chromosome 22 del • Gonadal Dysgenesis • (45, X) • Skeletal Dysplasia

28. Management Tips • If clinically and socially stable, give yourself time and use frequent observational follow up • Even if clear organic cause evident do not forget about psychosocial components – most organic causes have mixed non-organic component • Be clear with family about seriousness of child’s status • insist they be seen • “Ring the Bell” - get all hands on deck

29. Management Tips • Look the grandmothers in the eye, get them on your side, ask them what they think is wrong and give them jobs • Ask all important members of the team for their assessment and theories on treatment • Normalize familial expectations • Access parental dietary attitudes • Unhealthy, sweet, hot/cold foods, fattening, food allergy

30. Management Tips • Ask every time you meet with the family • Diet • “What are you feeding the child?” • Caloric Intake • “What exactly did your child eat in the last 24 hours?” • Eating Environment • “How are you feeding the child?” • “What do you Think about your child’s feeding”

31. Expected Daily Weight Gaingrams/day 0 to 3 months 30 3 to 6 months 18 6 to 9 months 12 9 to 12 months 9 1 to 3 years 8 “Catch Up” weight gain is two to three times greater than average for age

32. Calculating Calorie Need Dietary Reference Intake (kcals/kg/day) 0 to 6 months 108 6 to 12 months 98 1 to 3 years 102 “Catch Up” calorie calculation 150% DRI Alternative method (DRI x median weight for length)/actual weight

33. Basal Intake Rate for Protein 2.2 grams/kg per day

34. Other Considerations • Calculated calorie requirements are estimates. Severe failure to thrive may require greater than 200kcal/kg • Target calorie intake should be achieved over 5-7 days • Malnutrition is usually associated with some degree of anorexia • High calorie feedings are hyperosmolar and may lead to diarrhea or malabsorption • Rapid refeeding may lead to hyperkalemia or hypophosphatemia

35. Vitamin and Mineral Supplementation • ZINC • No reliable lab assessment • Baseline addition • IRON • If Hemoglobin, Hematocrit or MCV labs indicate further work up add to diet

36. Feeding Strategy • Start with small quantities and advancing as tolerated • Pushing feeding further apart • Assisted feeding to help caregiver recognizing and responding to cues of hunger and satiety, identify active feeding • Monitoring latch quality and persistence of latch

37. Increasing Milk Caloric Content - INFANTS • Breast Milk • 22 kcal/oz: add ½ scoop of formula to 4 ½ ounces • 24 kcal/oz: add 1 scoop of formula to 5 ounces • Formula • 22 kcal/oz: add 2 ½ scoops of formula to 4 ½ ounces of water • 24 kcal/oz: add 3 scoops of formula to 5 ounces of water

38. Increasing Milk Caloric Content - CHILDREN • Increase calorie content of foods child likes to eat • Adding rice cereal to pureed foods • Replacing milk with high calorie substitutes • Limiting low nutrition liquids • Adding cheese, butter, sour cream, peanut butter to fruits and vegetables • Total energy and protein is more important than variety

39. Increasing Milk Caloric Content - CHILDREN

40. Increasing Caloric Density of Foods for Toddlers

41. Other Recipes • 8 ounces of whole milk plus 2 Tbsp nonfat dry milk powder = 24 calories/ounce • 8 ounces of whole milk plus 3 Tbsp nonfat dry milk powder = 28 calories/ounce • 1 cup of whole milk, 1 package of instant breakfast and 1 cup ice cream = 430 calories

42. Adequate Response • With adequate caloric and protein intake, “Catch Up” growth is initiated in 2 to 14 days • 4-9 months of accelerated growth must be maintained to restore a child’s weight to height • “Catch Up” height may lag behind weight by several months

43. Medical Appetite Stimulation Cyprohepatidine has no proven long-term benefit Lemons PK, Dodge NN. Persistent failure-to-thrive: a case study. J Pediatr Health Care 1998; 12: 27.

44. Indications for Hospitalization • Severe malnutrition • Significant dehydration • Serious medical problems • Psychosocial risk to child • Failure to respond to outpatient • management • Precise documentation of caloric intake • Extreme parental impairment or anxiety • Severely disrupted parent-child axis • Family issues make outpatient therapy impractical

45. Supplement Oral Feedings • Severe malnutrition that is not achieving adequate catch up in 4 to 6 weeks consider nasogastric feedings • Discontinue when consistent weight gain has been shown for 4 to 6 months • If weight gain remains inadequate after 3 to 4 months of nasogastric feeds gastrostomy tube may be appropriate

46. Frequent Follow Up • Weekly follow up should continue until solid baseline growth is demonstrated • Use ancilary team members for observation • Home health nurse • WIC • Dietitian

47. Refeeding Syndrome • Sweatiness • Hyperthermia • Hepatomegaly – increased glycogen deposition • Widening of the cranial sutures- brain • growth faster than the skull • Increased periods of sleep • Fidgetiness or hyperactivity

48. Refeeding Syndrome • Follow Potassium and Phosphorus in the acute period of reinstating nutrition • Initial intracellular ion shifts my cause • Hypokalemia • Hypophosphotemia • Can produce serious arrhythmias and muscle weakness

49. Can laboratory studies help diagnosis and management?

50. Can laboratory studies help diagnosis and management? Not Usually Sills et al (1978) 2607 laboratory tests were undertaken for the entire study group of 185 children hospitalized for failure to thrive. Only 36 (1.4%) of tests were of positive diagnostic significance. All of them were in the 34 patients whose diagnosis was strongly suggested by history and examination. Homer et al (1981) 82 children hospitalized for failure to thrive. History and examination was most sensitive indicator of organic disease. Berwick et al (1982) 122 infants hospitalized for failure to thrive. Only 0.8% of tests were of positive diagnostic significance and 3.8% contributed to management. GI related labs were most helpful but indication for labs usually appearant in history and examination.