2. Failure to Thrive Rafat Mosalli MD FRCPC FAAP

3. Overview Definitions Diagnosis Treatment Outcomes

4. Definition Failure to Thrive (FTT): –Weight below the 5 th percentile for age and sex –Weight for age curve falls across two major percentile lines –weight gain is less than expected Other definitions exist, but are not superior in predicting problems or long term outcomes

5. FTT : –A sign that describes a problem rather than a diagnosis –Describes failure to gain wt In more severe cases length and head circumference can be affected Underlying cause is insufficient usable nutrition to meet the demands for growth Approximately 25% of normal children will have a shift down in their wt curve, then follow a normal curve -- this is not failure to thrive

6. Introduction Specific infant populations: –Premature/IUGR – wt may be less than 5 th percentile, but if following the growth curve and normal interval growth then FTT should not be diagnosed

7. Types Organic (30%) – 2º to a disease process –medical treatment needed for illness Non-organic (70%) – under feeding & psychosocial disturbance requires a change in the child’s environment Mixed

8. More useful classification system is –Inadequate caloric intake –Inadequate absorption –Increased energy requirements

9. Etiology Inadequate Caloric Intake –Incorrect preparation of formula –Poor feeding habits (ex: too much juice) –Poverty –Mechanical feeding difficulties (reflux, cleft palate, oromotor dysfunction) –Neglect Physicians are strongly encouraged to consider child abuse and neglect in cases of FTT that don’t respond to appropriate interventions*

10. Etiology Inadequate absorption –Celiac disease –Cystic fibrosis –Milk allergy –Vitamin deficiency –Biliary Atresia –Post-Necrotizing enterocolitis

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

12. Diagnosis Accurately plotting growth charts at every visit is recommended* Assess the trends H&P more important than labs –Most cases in primary care setting are psychosocial or nonorganic in etiology

13. History 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?

14. Changes in growth due to FTT early finding –weight late findings –length –head circumference

15. Growth charts of an 8 month old boy with Non-organic FTT

16. Physical Wt, Ht, HC with the growth chart Systemic exam Signs of neglect or abuse Inappropriate behavior

17. 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?

18. Physical Indications of Non-organic FTT –Lack of age appropriate eye contact, smiling, vocalization, or interest in environment –Chronic diaper rash –Impetigo –Flat occiput –Poor hygeine –Bruises –Scars

19. Rule 1  if Hx & exam is negative unlikely to find a cause Rule 1  if Hx & exam is negative unlikely to find a cause Rule II  NO FISHING Rule II  NO FISHING Rule III  Guided by finding Hx and exam. Initial work up * CBC-d + ESR * Electrolyte profile * Urine analysis * Stool analysis * Bone profile. Specific investigations. A B  Investigations

20. TREATMENT 1)Urgent problems e.g. electrolyte, infection, dehydration. 2)Nutritional rehabilitation: catch up growth requirement.

21. 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

22. Management Energy intake should be 50% greater than the basal caloric requirement Concentrate formula, add rice cereal 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

23. Management Parental behavior modifications: –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

24. Indications for hospitalization Rarely necessary weight below birth weight at 6 wks signs of physical abuse failure of out-patient therapy Hypothermia, bradycardia, hypotension safety is a concern work-up needed for organic causes

25. Management For difficult cases: –Multidisciplinary team approach produces better outcomes Dietitians Social workers Occupational therapists Psychologists –NG tube supplementation may be necessary

26. HISTORY AND PHYSICAL EXAMINATION “Organic Cause” Cause Not Obvious Feeding Disorder orBehavioralorPsychosocialEtiology Investigati on and Managemen t as Indicated Laboratory Screening Tests PositiveNegative Treatment Malnutrition andMultidisciplinaryServices INFANT WHO HAS FTT

27. Prognosis of non-organic FTT * Retardation (15 - 67%) *School learning (15 - 67%) *Behavioral disturbance (28 - 48%) Persistent disorders of growth increased susceptibility to infection

28. CONCLUSION 1)FTT is a SIGN only 2)The most important diagnostic method is :HISTORY & EXAM. 3)The important of Nutrition for the brain development in the first 2 years of life.

29. Top 6 take home points 1.Evaluation of Failure to Thrive involves careful H&P, observation of feeding session, and should not include routine lab or other diagnostic testing 2.Nutritional deprivation in the infant and toddler age group can have permanent effects on growth and brain development 3.Treatment can usually occur by the primary care physician in the outpatient setting.

30. Top 6 take home points 4.Psychosocial problems predominate as the causes of FTT in the outpatient setting 5.Treatment goal is to increase energy intake to 1.5 times the basal requirement 6.Earlier intervention may make it easier to break difficult behavior patterns and reduce sequelae from malnutrition

31. References 1.Block RW, Krebs NF. Failure to thrive as a manifestation of child neglect. Pediatrics 2005 Nov; 116(5):1234-7. From National Guidline Clearinghouse – www.guideline.gov www.guideline.gov 2.Kirkland, RT. Failure to thrive in children under the age of two. Up to Date: http://www.utdol.com/utd/content/topic.do?topicKey=gen_pedi/2884&type=P&select edTitle=6~29 version 14.2, april 2006:pgs 1-8. http://www.utdol.com/utd/content/topic.do?topicKey=gen_pedi/2884&type=P&select edTitle=6~29 3.Krugman SD, Dubowitz H. Failure to thrive. American Family Physician, sept 1 2003. Vol 68 (5). 4.Kane, ML. Pediatric Failure to Thrive. Clinics in Family Practice. Vol 5, #2, June 2003, pages 293-311. 5.Agency for Healthcare Research and Quality (AHRQ); Evidence report: Criteria for Determining Disability in Infants and Children: Failure to thrive. #72, pages 1-54. http://www.ahrq.gov/clinic/ http://www.ahrq.gov/clinic/ 6.Bauchner, H. Failure to thrive, in Behrman: Nelson Textbook of Pediatrics, 17 th ed, chapter 35, 36 - 2004. 7.Rudolf M, Logan S. What is the long term outcome for children who fail to thrive? A systematic review. In Arch Dis Child 2005;90;925-931.