1. While you wait, please plot out our patient’s growth
Birth wt: 3.4 kg ht: 51 cm hc: 35 cm
2 mo wt: 5.0 kg ht: 58 cm hc: 39 cm
4 mo wt: 6.3 kg ht: 63 cm hc: 41 cm
6 mo wt: 7.4 kg ht: 67 cm hc: 42.6 cm
12 mo wt: 7.8 kg ht: 75 cm hc: 45.2 cm

2. Geneviève Moreau June 9th 2015
Failure to Thrive
Geneviève Moreau
June 9th 2015

3. Objectives
Identify normal and abnormal patterns of infant growth (see attached growth charts)
Correctly plot and interpret grown parameters, with an understanding of growth velocities and relationships between growth parameters
Develop knowledge of normal infant nutrition
Identify failure to thrive and describe its causes, evaluation, management, and sequelae

4. Normal Growth Patterns
What is a normal birth weight for a baby born at term? 3,25 kg (7 lbs) +/- 2SD From the 10th-90th percentile (2,8-4,0 kg) What is the accepted weight loss within the first week of life? 10% When should the newborn have regained this weight? d

5. Normal Growth Patterns
What is the expected rate of weight gain in the term newborn? g/d Doubled at 4-5 mo Tripled at 1 yr Quadrupled at 2 yrs

6. Failure to Thrive Indications for Investigation
Weight < 3rd percentile
Weight falls across 2 major percentile curves
Weight < 80% of expected value for height and age
1- Determine length for age percentile
2- Determine weight for age corresponding to that percentile
Rate of daily weight gain less than expected for age
0-3 mo g/d
3-6 mo g/d
6-9 mo g/d
9-12 mo g/d
1-3 yrs 7-9 g/d

7. Case 1
Lynn Thin, a 13 month old girl has just moved to your community and is coming to see you for the first time. Her previous family physician noted that her weight hadn’t increased as expected when he saw her just before moving. Lynn and her mother arrive for the appointment with a list of her previous growth measurements.
What should we ask on history?

8. History Nutritional intake Duration of mealtimes Type of food
Quantity of food
Food preference and avoidance
Juice ingestion
Dietary restrictions, allergies
Current symptoms
Vomiting
Diarrhea
Rumination
Developmental history
Psychosocial history

9. History Prenatal and perinatal history Birth weight IUGR
Perinatal stress
Prenatal exposures (medications, drugs and alcohol)
Past medical history
Chronic diseases
Past illnesses
Frequent recurrent infections
Frequent injuries
Family history
Growth and puberty
Parental height and weight
Genetic disorders and syndromes

10. History
On history, you find out that Lynn is a first child of healthy parents. Her 23 year old mother smoked during pregnancy, but did not use any alcohol or drugs, and had no medical problems. Lynn was born 10 days early by spontaneous vaginal delivery. She was breastfed until 7 months of age, when her mother had to go back to work. She was started on milk at that time. Solid foods were introduced starting at 8 months. She currently drinks 5 large bottles of milk per day and eats table foods. Her parents find that she is a picky eater and spits out foods that she does not like. They tend to stick to her favourites – applesauce, cookies, and pasta. They are quite frustrated with the difficulties around mealtimes.
Lynn has had no medical problems. She has attended all scheduled medical appointments and her vaccinations are up to date. Lynn’s mother reports that she has a distant cousin with cystic fibrosis and another cousin with a “hole in the heart”. She is worried that Lynn may have one of these problems. Lynn’s development is appropriate for her age. Her mother is working part-time as a cashier and her father was recently fired from his job in construction.
Nutrition
exclusive breastfeeding until 6 mo with vit D supplementation
followed by gradual introduction of solids
important to introduce iron-containing foods, as breastmilk does not contain iron and the baby’s store of maternal iron runs out at 6 months
6-9 mo: introduction of solids
starting with iron rich foods (meats, enriched cereals)
then pureed veggies
then fruits
9-12 mo: introduction of finger foods, switch to homo milk
limit cow milk to 600 mL/day (16 oz/d) from the age of 1-5 yrs old
Breastmilk content
colostrum (first few days): high protein, low fat, immunoglobulin
70:30 whey:casein ratio, dietary butterfat, lactose
Cow milk vs Breastmilk
- lower whey:casein ratio, plant fats

11. Physical Growth (height, weight, head circumference) Head to toe
Dysmorphic features
Tanner staging
Signs of abuse or neglect
Signs of vitamin deficiency

12. Physical
On examination, Lynn is slim and slightly pale. She is cheerful and interactive. Her head-to-toe exam is otherwise normal.

13. Mrs. Thin is very worried about her daughter
Mrs. Thin is very worried about her daughter. She wants to know what the problem is, what investigations need to be done, and whether Lynn’s poor growth will cause long-term problems.

14. Important to ask about changes in the child’s life and environment at the time of the change in slope
Must correct for GA if premature (~ 2 yrs)
Need 2 points that cross the threshold for investigation

16. Is Lynn’s growth pattern normal?

17. Differential Diagnosis FTT (Wasting)
Inadequate Intake
Low volume
Diet lacking in nutrients
Oromotor dysfunction (neuro, ENT, esophageal)
Anorexia (psychosocial, chronic disease, malignancy, meds)
Inadequate Absorption or Increased Losses
Vomiting
Malabsorption (lactose intolerance, cystic fibrosis, IBD, celiac)
Biliary atresia
Bowel obstruction (pyloric stenosis, malrotation, intussusception)
- 90% have non-organic cause (dietary intake, feeding environment, stress)

18. Differential Diagnosis FTT (Wasting)
Increased Needs or Ineffective Utilization
Chronic disease (IBD, heart disease, cystic fibrosis, CKD)
Chronic or recurrent infection (TB, HIV, toxoplasmosis)
Malignancy
Chronic metabolic problems (DM, hyperT4, adrenal insufficiency)
Based on the history and exam, what investigations, if any, should be considered?
Note: Endocrine disorders are more likely to present as short stature

19. Investigations FTT (Wasting)
To be considered based on presentation:
Food journal
CBC, smear
Lytes
Ferritin, Fe, TIBC
Vitamin levels
GI workup:
OT evaluation, baryum swallow
Celiac screen (anti-tTG, IgA)
Crohn’s screen (scope, biopsy)
Endocrine workup:
TSH, T4
Etc etc

20. Follow-Up FTT (Wasting)
Catch-up growth (rate of weight gain 2-3 times the normal range) can be seen from 2 days to 2 weeks after then start of an intervention
Failure to achieve catch-up growth after 2-3 months of primary care intervention should be referred to a specialist/multidisciplinary team
NG tube feeding is indicated if there is no catch-up growth after 4-6 wks with adequate oral intake
Gastrostomy tube is indicated if weight gain is inadequate after 3-4 mo of NG tube feeding
NG feeding indicated if no catch-up growth after 4-6 wks with adequate oral intake
Gastrostomy tube indicated if weight gain inadequate after 3-4 mo of NG feeding

21. Sequelae FTT (Wasting)
Cognitive deficits Behavioral problems Learning difficulties
50% of children with FTT have below normal cognitive function
it is uncertain whether this is a result of the FTT or of coexisting psychosocial factors

22. Case 2
Your next patient, Julie Petit, is a 24 month old girl who comes in for her routine vaccinations. As usual, you add the latest growth measurements to her chart.

24. Differential Diagnosis Short Stature

25. Differential Diagnosis Short Stature
Endocrine disorders (hypoT4, Cushing’s, GH deficiency, CNS tumor)
Rhumatologic disease (JIA)
Renal disease
Malignancy
This is Ddx for baby/infant; there are more ddx for older children

26. Case 3
Your next patient, William Turner, is brought in by his parents who are worried because “he is much smaller than all of the other kids his age”. After performing a complete history and physical exam, you plot out his latest growth points.

28. Differential Diagnosis Proportionally Small Weight and Height

29. Differential Diagnosis Proportionally Small Weight and Height
Familial short stature Constitutional growth delay IUGR Syndromes and chromosomal disorders (Turner, Down, Prader-Willi, Russell-Silver) Skeletal dysplasia (scoliosis, achondroplasia)
IUGR babies expected to catch up by 2 yrs
Russell-Silver: IUGR + post-natal growth retardation + facial features (prominent forehead, triangular face, downturned corners of mouth + body asymmetry
- facial features become less apparent with age
Proportionate: IUGR, chromosomal
Disproportionate:
- U/L ratio elevated: achondroplasia
- U/L ratio low: scoliosis
Normal U/L ratio
1.8:1 in newborns
1:1 in 8 yo

30. Calculations Proportionally Small Weight and Height
Mid-parental height Boys: (father + mother + 13 cm)/2 Girls: (father + mother - 13 cm)/2 Predicted definitive height Bony age determination by XR
Mid-parental height
target height = this value +/- 10 cm
determine the percentile of the target height in adults
the child should be within that percentile
Compare bony age to chronological age
BA = CA: likely familial
BA < CA: likely constitutional delay

31. Thank You

32. Extras

33. Management of the normal growth pattern and a worried parent
Reassure
In the first 3 years of life, children’s percentiles may fluctuate (it should not change from 3 yrs of age until puberty)
Breastfed babies tend to grow faster in the first 6 months of life, whereas formula-fed babies grow faster after 6 months
Continue to monitor growth
In the first 2 yrs of life of normal children:
30% cross 1 major percentile line
23% cross 2 major percentile lines

34. Counselling the parent of a picky eater
Allow the child to develop a sense of autonomy
Eat as a family
Create a positive atmosphere at the table
Encourage exercise and play
Give time to prepare and settle down before meals
Limit time at the table
Limit distractions at the table
Avoid grazing between meals and snacks
Avoid excessive amounts of milk or juice
Avoid coaxing or coercing