FAILURE TO THRIVE By William Bithoney Patrick Casey Robert Karp S U

Failure to Thrive Abnormal weight status during infant-toddler years and/or Abnormal weight gain (weight growth velocity)

Abnormal weight status Referenced against: Genetic growth expectations for family Children of same gender and gestation adjusted age <5% on NCHS curves Child's own length <10-25% on NCHS curves

Abnormal weight gain (Growth Velocity) Falling across two standard deviation percentile lines on NCHS curves over 6 month period For at least one to two months

FTT Definition includes: "light" "thin" atypical weight gain

Cautions Regarding Definition of Failure-to-Thrive Genetically small due to parents size Children born small for gestational age (SGA) may never catch up If born larger than long-term genetic potential demonstrate decreased growth rate in first 2 years

FTT Definition: Growth Only Not necessarily associated with developmental/emotional problems in child Not necessarily environmental causation

What's in a name? Growth Delay Growth Failure Failure to Grow Growth Deficiency Failure to Gain Weight

FTT of long duration (Grown Older) STUNTED: Abnormal length and head circumference Psychosocial Dwarf?

Failure-to -thrive Cause: All children with Failure-To Thrive are Undernourished

Three Methods to Categorize Undernutrition in Children McLaren, Read: % median wt/ht for age ratios >90 85-90 75-84 <75 Gomez: % median weight- for age >90 75-90 60-74 <60 Waterlow: % median weight- for-height >90 80-90 70-79 <70 Degree of Under- Nutrition None Mild Moderate Severe

Categorization of Undernutrition in 258 Children Referred for "Failure to Thrive" McLaren, Read No. 18 38 156 46 Degree of Under- Nutrition None Mild Moderate Severe Gomez No. 5 132 112 9 Waterlow No. 64 149 42 3 % 2 51 43 4 % 25 58 16 1 % 7 15 60 18

Clinical Subtypes I. Medical Cause II. Clinical Presentation Organic vs. Non-organic vs. Mixed II. Clinical Presentation Age of onset Severity Chronicity

Non-organic Etiology: medical disease present and clinically judged to be sole cause of FTT Non-organic Etiology: problems in the child's environment judged to be the primary cause of FTT, in the presense or absence of medical disease MIXED Etiology: medical problem and problems in environment in combination are judged to be cause of FTT

Problems with Organic/Non-Organic Dichotomy 1. It is often difficult to place a child in either category 2. The dichotomy fails to account for the compounding effect of problems in both the child and the environment

Problems with Organic/Non-Organic Dichotomy (Cont'd) 3. Children with either may have symptoms like diarrhea or vomiting 4. Children with either may gain weight while in the hospital 5. Global terminology is not specific enough to develop an individualized management plan

Clinical Subtypes (Cont'd) III. Socioemotional 0-3 months 4-10 months 11-36 months Homeostasis Attachment disorder Separation individuation disorder

Clinical Subtypes (Cont'd) IV. Psychiatric Diagnoses Feeding Disorder Depression Reactive Attachment Disorder V. Mechanical Feeding Disorder Food Avesion

Transactional FTT Multiple aspects (overt or subtle) of child, parents, and the proximal and distal environments interact across time to result in FTT.

Final Diagnosis of 131 Cases of Failure to Thrive Number 59 46 22 4 Percent 45 35 16.7 3.3 Non-organic Interactional Organic Unknown

Frequency of Organic Systems Causing Failure to Thrive Gastrointestinal Neurological Respiratory-Pulmonary Cardiovascular Endocrine Other Most Common Least Common

Prevalence of Failure to Thrive 3.5% of admissions to children's hospitals 10% of clinic visists in urban and rural outpatient settings up to 16% 0-4 year olds in low income populations are "stunted"

Failure to Thrive Weight is abnormally 2 standard deviations below the mean for gestation corrected age -- and/or weight crossess percentile curves by two standard deviations weight to height ratio is depressed

"My baby is just small for her age" -Parent

Failure to Thrive: Spectrum of Causes Problem in the Child ORGANIC Problem in the Environment NON-ORGANIC Interactive Effects

Parent Functioning Child Outcomes Development Learning Behavior Growth Health

Goals of Clinical Evaluation Identify conditions which: 1. Negatively affect growth potential (disease) 2. Increase basic caloric needs (e.g. chronic infection) 3. Decrease availability/utilization of calories (e.g., malabsorption) 4. Negatively affect parents ability to meet nutritional needs (can't/won't eat)

Diagnostic Evaluation 1. Growth assessment confirm the diagnosis with weight and height, present and past 2. History predisposing factors 3. Physical examination significant findings other than malnutrition

Diagnostic Evaluation (Cont'd) 4. Development-Behavioral Assessment Assess delays in cognitive, language, or motor functioning Identify any behavioral abnormalities 5. Laboratory Evaluation Varies for each child Stepwise approach is recommended

Laboratory Evaluation Should be directed by findings from the history and physical examination Document nutritional status: albumin, iron, zinc Child may have endemic problem: Tbc, AIDS, giardia

Diagnostic Evaluation (Cont'd) 6. Nutritional and Feeding Evaluation Content and structure of mealtimes Feeding techniques 7. Social History Identify parental/family strengths and weaknesses

Diagnostic Evaluation (Cont'd) 8. Parent/Child Interaction Especially as it relates to feeding 9. Psychiatric Evaluation Important if the caregivers emotional state is adversely affecting parent-child interaction

Hospitalization vs. Outpatient Care Advantages of hospitalization: Able to observe and control feeding Able to observe the parent-child interaction Medical evaluation can be done easily Disadvantages of hospitalization: Cost Child (and parent) are away from their normal environment

Indications for Hospitalization of Children with Failure-to-Thrive 1. Evidence of physical abuse 2. Extreme failure to thrive (starvation) 3. Extremely dysfunctional parent-child relationship or family 4. When distance and transportation issues mean outpatient management is not practical 5. When outpatient management has failed

Management of the Child with Failure-to-Thrive 1. Nutritional asessment and intervention 2. Improved parent-child interaction 3. Developmental stimulation 4. Treatment/management of medical conditions 5. Support and intervention for social and family problems 6. Mental health referrals where indicated 7. Regular follow-up care

Best Predictors of Prognosis Age of onset, chronicity Ongoing quality of the home environment

Interactional Model of Failure-to-Thrive PARENT Economic Status Health Knowledge Emotional State Past Experience CHILD Appearance Neuro developmental maturity Ease of Caregiving Parent-Child Interaction Failure-to-Thrive Endocrine-Cellular Dysfunction Nutritional Deficiency

Environmental Characteristics: Supports and Stressors Home -Marital Relationship -Physical Quality -Organization -Stability -Economic Resources Family Neighborhood and Work