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Kathleen D. Asas Inpatient Pediatrics 4/1/11

Failure-to-Thrive: A Multifactorial Approach. Kathleen D. Asas Inpatient Pediatrics 4/1/11. To discuss the definition of failure-to-thrive To review appropriate growth trends in pediatric patients To discuss basic history-taking and physical exam findings in FTT

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Kathleen D. Asas Inpatient Pediatrics 4/1/11

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  1. Failure-to-Thrive: A Multifactorial Approach Kathleen D. AsasInpatient Pediatrics4/1/11

  2. To discuss the definition of failure-to-thrive To review appropriate growth trends in pediatric patients To discuss basic history-taking and physical exam findings in FTT To gain comfort in management of FTT Objectives

  3. Weight < 5th percentile for age Note: Using special growth charts when indicated (e.g., prematurity, Down syndrome, Turner syndrome) • A rate of weight gain that is exhibited by a decrease in 2 major percentiles over time • Weight for length < 5th percentile for age • Lack of height growth due to poor weight gain over time that cannot be attributed to an identifiable organic cause • Lack of appropriate growth in head circumference following previous decrease in height growth rate and poor weight gain that cannot be attributed to an identifiable organic cause What is failure-to-thrive? National Clearinghouse Best Practices Guidelines on FTT 2009

  4. Severity of nutritional deficit • What’s the significance? • Weight for age is the most powerful predictor of mortality • Highest risk of mortality  both weight: height and height for age are depressed • Depressed length or height for age is considered a manifestation of cumulative • effects of malnutrition • Depressed weight for height indicates acute and recent nutritional deprivation

  5. Weight: • Regain BW by 2 weeks of life • Double BW by age 4 months, triples by 12 months and quadruples by 24 months • After age 2, wt gain is 5lbs/yr until adolscence Length/Height: • Birth length increased by ½ at 1 yr • Doubles by 4yr • Triples by 13 yr • > 2 yrs, avg ht increase is 2 inches/yr until adolescence Head Circumference: • Largest rate of growth is btwn 0-2 months (0.5cm/week) • Term infant female avg HC= 35 cm; male avg HC = 36cm Quick pearls of Growth

  6. correct for weight-for-age until 24 months chronological age • correct for height-for-age until 40 months chronological age • correct for head circumference until 18 months chronological age • Most preterm infants have catch-up growth by 2-4 yrs old Correction for prematurity

  7. Common Causes of Malnutrition in Early Life

  8. Another way to think about causes of FTT Inadequate Caloric Intake/Retention • Inadequate amount of food provided • Poor breast feeding technique • Structural causes of poor feeding eg cleft palate • Persistent vomiting • Anorexia of chronic disease Inadequate Absorption • Coeliac disease • Chronic Liver disease • Pancreatic insufficiency eg Cystic Fibrosis • Chronic diarrhea • Excessive Caloric Utilisation • Urinary Tract Infection • Chronic Respiratory disease eg Cystic Fibrosis • Congenital Heart disease • Diabetes Mellitus • Hyperthyroidism Other Medical Causes • Genetic syndromes • Inborn Errors of Metabolism Psychosocial factors • Parental depression • Coersive feeding • Distractions at meal times. • Poverty • Behavioural disorders • Poor social support • Neglect

  9. FTT clinical pathway

  10. NAME THAT GROWTH CHART……

  11. Name that growth chart….. Growth hormone deficiency In-utero etiology Wt and length are delayed with normal HC think endocrinopathies, constitutional growth delay or even long-standing undernutrition….. Poor wt, length, and ht since birth

  12. Acquired hypothyroidism Constitutional growth delay

  13. Cushing syndrome…rapid wt gain (central obesity) with attenuation of linear growth FTT from recent caloric deprivation

  14. Step 1: Plot your growth chart Step 2: Determine if patient is on appropriate formula and if other organic factors are involved (i.e. GER, swallowing dysfunction, underlying cardiac/resp/metabolic disorders) Step 3: Watch parent and child interaction AND observe a feeding session! Step 4:Determine catch-up growth in kcal/kg/day Management KeyPoints in the Inpatient setting

  15. Step 5: What to include in your orders: • Daily weights, same time, same scale • Strict I/Os with strict calorie count (watch for increased stool output and consistency of stools) • Feeding diary for parent at bedside (including duration of feedings, volume fed, episodes of vomiting, parent observations) • Thorough diet plan based on catch-up growth estimates • Baseline labs (CBC with diff, lead, U/A) • Social work and Nutritionist consults Management KeyPoints in the Inpatient setting

  16. 100-110 kcal/kg/d for 0-6 months 100 kcal/kg/d for 6-12 months 10-20kg, need 50 kcal/kg/d is required until 20 kg > 20kg, need 20kcal/kg/day Protein requirement for catch-up growth: 2.2g/kg/day General Rule: Minimal goal for catch-up growth is 2-3 times the average rate of wt gain for corrected age. Estimates of Caloric requirements (RDA)

  17. Step 1: Catch-up growth • (kcal/kg/day) = RDA (kcal/kg/day) x ideal weight for height current weight (kg) • Step 2: Choosing an appropriate feeding regimen: • Breastmilk (20kcal/oz) vs Standard Enfamil/Similac (20kcal/oz) vs higher caloric density formula (22kcal, 24kcal). • Note: Gradual transition to higher caloric density formula is preferred. Why? • increased renal solute load and hyperosmolarity causes diarrhea/stool malabsorption with increased caloric density formula!! • Usually max 24kcal/oz, gradual increase by 3kcal/oz if needed. • 27kcal and 30kcal/oz formulas reserved for fluid-restricted pts Calculating Catch-up growth

  18. Assess DAILY caloric intake in kcal/kg/day…is this close to catch-up growth estimates? • Monitor weight gain over 5-7 days • Weight gain in first few days of re-feeding may not be reflective of true weight gain. • Why? Extracellular fluid overload Daily Inpatient Assessments…is your management plan adequate?

  19. Clear plan of follow-up with a PMD Weight checks (set-up through Visiting Nurse Service) Concrete feeding plan, discussed with parents and caregivers prior to discharge (it helps to write out a plan for parents). Treatment of co-morbidities Identify appropriate psychosocial services needed: WIC, parental support groups, and other family services needed. On discharge:

  20. Child is able to maintain weight for height above 10th percentile Normal rate of weight gain on at least 2 assessments 1 month apart on a NORMAL diet for age Endpoint of nutritional rehabilitation

  21. FTT reflects multiple factors including medical, nutritional, developmental, social, and financial. • Obtaining clear prenatal, postnatal, and nutritional history is essential. • Management of FTT requires knowledge of average growth rates, recommended food choices for age, and barriers to obtaining nutrition. • References are at your fingertips! • CDC • Pediatric Handbook of Nutrition • AAP Guidelines FTT keypoints

  22. Case-bAsed Module

  23. You are supervising a "well baby" visit in a busy public health clinic, a medical student asks you to look in on a 10 month old boy "who looks kind of small for his age." • Danny is here with his mother today.  The mother appears “scruffy looking.” His mother says she is not worried about the baby's size because baby was "born real small, a seven months baby."   • On further questioning she remembers that Danny was due on May 1st, but was born on March 1st, 10 months ago with a birth weight of 3lb 12oz (which the medical student helpfully translates to 1,700 grams). • The medical student thinks the baby's current weight (obtained by "throwing the baby on the scale" which may or not have been zero set) is "about 15 lbs."  • Once you have the mother peel off the snow suit, boots, turtle neck, overalls and wet diaper, the baby's unclothed weight today is 13lb 2oz (6 kg), length 25.6 inches (65 cm), head circumference 27inches (42 cm). Case Study Part 1

  24. Growth chart

  25. Yes! Here’s why: If have one set of data: - Weight < 5th percentile - Wt: length < 3rd percentile - Wt < 70th percentile of ideal body weight If have 2 sets of data: - Wt falls more than 2 growth percentiles. Does this infant have FTT?

  26. Even after correction for prematurity, the child is below the fifth percentile weight for corrected age and weight for current length. • The medical student wants to know if the FTT is "organic or non-organic."  As you start to elicit medical history, mother, who appears quite thin, assures you that she is Vietnamese and that the baby's father is white, but not much taller than she is (5' 3").  She adds, "we're all just small." Nutritional history: • mother pumped breast milk for feeding of the baby for the first month in the NICU and then transitioned to milk based preemie formula.  • He is now on iron milk - based term formula when available.  • When it is not available, his mother gives him dilute condensed milk with Karo syrup. • The baby began spoon feeding at 6 months chronological age.  • His mother says that he is "gaggy" and sometimes pushes the food out. So, his mother has been adding mixed grain cereal to his bottle and has made a larger hole in the bottle nipple to allow for feeding.  • In the past month, he has begun to mouth crackers. He is not on vitamins or iron. Case part 2:

  27. Mother says that she mixes the formula the way that it says on the can when she has enough.  • She says that she uses more water.  She can't afford to buy the formula, so the father of the child brings some when he can.  • She says that her grandmother taught her that putting cereal in the bottle will help the baby to feel fuller and mom has noticed that he doesn't spit as much with the cereal in the bottle.  • You ask if anyone else in the family ever feeds the baby.  Mom enjoys feeding the baby, especially Vietnamese rice soup in his bottle.  She feeds him when he wakes up-he is a good sleeper-12 hours a night and two long naps.  • "So how often is he fed?"  She says that he eats about four times a day.  His mother adds that he doesn't like to eat and the nurses said not to force him.  Case Part 3:

  28. Will a hospitalization always promote a better outcome than outpatient services for children with FTT? • Why discourage hospitalization? • What criteria should be used for hospitalizations? • Let’s discuss! • How much weight should be gained? • Refer to table 10 • What social variables contribute to FTT? • Poverty, family discord or domestic violence, parental depression, intellectual impairment of caregiver(s), or psychiatric disorders.  • Social isolation, negative family dynamics, previous family trauma, and chaotic or over-controlled feeding interactions questions:

  29. LT is a 4-mo old FT male BIB by ACS with mother for poor weight gain. He was seen by his PMD 2-wks prior for weight check, PMD noted poor weight gain clinic wt- 3900g;, current wt-3875g. LT was scheduled for a weight check but mom never showed up, PMD notified ACS. • What questions would you ask mom at this point? • ROS: no fevers, no cough/congestion, + frequent spit-ups with feeds. • Diet/detailed feeding history- Enfamil 4oz q3hrs. Mom had changed from Similac to Enfamil 2 wks prior. Mom and GM share duties with feeding the baby. • PMH-None BHX:FT/NSVD @ Lincoln Medical Center. BW-3200g; no birth complications, Apgars 9/9. NBN screen neg. Maternal serology negative. • SHX- Mom is a 23 y/o G1P01, they live in a shelter. GM lives nearby and helps care for baby. Mom has a h/o post-partum depression. Case 2

  30. Physical exam V/S: T-97.6 P-147 RR-57 BP-99/61 02Sat-100% (RA) GEN: Small-for-age, vigorous, alert HEENT: NCAT, AFOSF, no syndromicfacies, B/L temporal wasting, RR+ B/L, no cleft lip/palate, no macroglossia, no bifid uvula, op-white exudate on B/L buccal mucosa and tongue CVS: RRR, nl S1S2, no murmurs, 2+ brachial & femoral pulses RESP: easy WOB, CTA B/L, no wheezes/crackles ABD: ND, BS+normoactive, soft, NT, no HSM, no masses GU: circumcized Tanner I male, tested desc. B/L BACK: no gross deformities EXT: W/W/P, no gross deformities, minimal subcutaneous fat SKIN: no rash NEURO: Good suck/grasp/rooting reflexes, equal extremity movements

  31. Growth charts CBC CMP Thyroid test What would you do next?

  32. cAse 2 Growth Charts

  33. Labs

  34. LT was treated for oral candidiasis, GERD with Prevacid, and placed on hypoallergenic formula Alimentum. Both ACS and VNS follow-up were arranged on discharge. Pt continues to have close PMD follow-up to-date. He is currently showing steady weight gain on Alimentum formula. His mother was referred for parenting services including support group for post-partum depression. Hospital course

  35. Appendix

  36. Improper feeding practices

  37. Taking a good history is key!

  38. Nutritional history checklist

  39. Bithoney W, Casey P, Karp, RJ. Why is Johnny Small? A case presentation module on Failure to Thrive: Curriculum for Poor and Underserved Children of the Ambulatory Pediatric Association, 2000 http://www.servingtheunderserved.org.html. Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt) failure to thrive treatment protocol. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2009 Jun 11. 5 http://www.cdc.gov/growthcharts/who_charts.htm http://www.downstate.edu/peds/Karp Nelson’s Textbook of Pediatrics 18th Edition. Failure-to-Thrive. references

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