Failure to Thrive

Susan Schayes M.D. Emory Family Medicine Emory SOM

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Failure to Thrive

Acknowledge Shannon Pittmann

In the State of Georgia, an adult is required to pass both a written and a road test to get a drivers license. No such requirement exists for parenting.

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Failure to Thrive

Objectives
To define failure to thrive (FTT) To identify major classification of FTT
To discuss diagnostic workup of FTT To discuss treatment of FTT

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Failure to Thrive

Failure to Thrive
A descriptive term, not a specific diagnosis Diagnoses when a childs weight for age is below the fifth percentile or crosses two major percentile lines The key is to accurately measure wt, ht at each visit.
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Failure to Thrive
A sign the describes a particular problem Requires us to STOP and THINK.

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Failure to Thrive

Failure to Thrive
Best defined as inadequate physical growth Diagnosed by observation of growth over time using standard growth charts. Preferred growth charts are from the National Center for Health Statistics (NCHS) found at www.cdc.gov
,
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FTT Criteria
Ht/Wgt less than 3rd to 5th percentile for age on >1 occasion Ht or Wgt falling 2 major percentiles Below 10th percentile for ht/wgt < 80% of ideal body wgt for age Head circumference important, but not part of FTT entity
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OK135S053

OK135S054

OK135S055

OK135S056

Selective Differential Dx
Inadequate caloric intake Inadequate absorption Increased metabolism Defective utilization

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Failure to Thrive, Am Fam Physician 2003;68:879-84

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FTT Definition
Inadequate physical growth diagnosed by observation of growth over time using a standard growth chart DO HT, WT and observe trends

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Were not alone

In England, 54% of GPs failed to diagnosis FTT Residency clinic, 41% with delayed Dx Residency clinic, 29 Dx, 100% Dx incorrectly
1. Batchelor JA. Has recognition of failure to thrive changed? Child Care Health Dev 1996;22:235-40 1/13/2014 2.Krugman et al. Missed opportunities to diagnose failure to thrive in a family medicine resident practice. Pediatr Res 2000:47

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FTT
HISTORY ! HISTORY! HISTORY!
Prenatal Feeding
# oz needed in 24 hours
Wgt (kgs) x 5 (need 100 kcal/kg/day, formula 20kcal/oz)

How formula prepared Good diet history (3 day journal)

Bowel habits
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Normal Growth
Average wgt 7 lbs (3kg)
Grow 25 cm in length during 1st year Make sure you have the right chart
Premature Breastfeeding Ethnic Down Syndrome www.cdc.gov/growthcharts
Failure to Thrive

Double by 4 months, triple by 12

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Normal Growth
Newborns can lose 10% of weight in first few days, gain back by 2 weeks Infants gain 1 kg/month 0-3 months gain .5 kg/month 3-6 months gain .33kg/month 6-9 months

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Bassali et al, Failure to Thrive www.emedicine,com/PED/topic7 38.htm, updated April 25, 2006

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Normal Growth
AGE Median Daily Weight Gain Grams 26-31 grams 17-18 grams 12-13 grams 9 grams 7-9 grams 6 grams
Bassali et al, Failure to Thrive www.emedicine,com/PED/topic7 38.htm, updated April 25, 2006

0-3 months 3-6 months 6-9 months 9-12 months 1-3 years 4-6 years

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Organic causes of FTT

Prenatal Causes Post natal causes Inadequate intake

Prematurity

Maternal malnutrition
Toxic exposure in utero Alcohol, smoking, meds Infections IUGR Abnormal chromosomes

Poor absorption & or use

Increased metabolic demand Inadequate absorption

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Bassali et al, Failure to Thrive www.emedicine,com/PED/topic7 38.htm, updated April 25, 2006

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Inadequate calorie intake

Incorrect prep of formula Unsuitable feeding habits Behavior problems affecting eating Poverty and food shortage Neglect, Disturbed parent-child relationship Mechanical feeding difficulties
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Inadequate absorption
Celiac disease Cystic fibrosis Cows milk allergy Poverty and food shortage Vitamin or mineral deficiency Biliary atresia or liver disease Necrotizing enterocolitis or short gut
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Increased metabolism
Hyperthyroidism Chronic infection- HIV, other immune diseases Hypoxemia-congenital heart defects and chronic lung disease

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Defective utilization
Genetic abnormalities- trisomies 21, 18, 13 Congenital infections Metabolic disorders- storage diseases, amino acid disorders

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Introduction to IEM
Usually a single gene defect that causes a block in metabolic pathways. Problems are because of accumulation of enzyme substrate behind the metabolic block or deficiency of the reaction product.

IEM
In some instances the substrate is diffusible & affects distant organs & in some there is just a local effect ( lysosomal storage disease ).

 Odors :

IEM Associations

Glutaric acidemia type 2 sweaty feet Isovaleric acidemia sweaty feet Hawkinsuria swimming pool MSUD maple syrup Methionine malabsorption cabbage Multiple carboxylase deficiency tomcat urine Oasthouse urine disease hops like PKU mousy or musty Trimethlyaminuria rotting fish Tyrosinemia rancid fishy or cabbage like

FTT
Physical
Gomez Criteria- comparing the current expected weight for age 50 percentile
<60% = severe; 61-75% = mod; 76-90% = mild

Kwashiorkor protein malnourishment Marasmus caloric deficiency Short Stature Syndrome Constitutional Delay
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FTT - Classification
Organic FTT
Pre/postnatal

Nonorganic FTT (NOFT)

Pre/postnatal

Mixed (25%)

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FTT - Classification
Nonorganic
Prenatal
Malnourished mother ? Lack of prenatal bonding

Postnatal
Poor feeding skills/disorder Dysfunctional family Difficult parent-child interactions Difficult Child Abuse/Neglect
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FTT - Classification
Organic, postnatal cont.
Poor absorption and/or use of nutrients
GI disorder (celiac, CF) Inborn errors of metabolism

Increased metabolic demand

Hyperthyroidism Chronic Disease

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FTT - Classification
Organic FTT
Prenatal Causes
Prematurity w/complications Toxic exposure

Postnatal
Inadequate intake
Lack of appetite Inability to suck/swallow

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Recap - Classification
Failure to Thrive

Organic

Nonorganic

Prenatal

Postnatal

Prenatal

Postnatal

Toxic Exposure

Inborn errors

Malnourished mother

Abuse/Neglect

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FTT - Workup
+/- Basic screening labs
CBC, Chemistry, & UA

Specific test directed by history

HIV, ESR, TSH, Sweat chloride test, serum IGF-I, serum IgA/IgG antigliadin antibiodies

X-rays for bone age

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FTT Treatment
High calorie diet for catch up growth
150% of recommended daily caloric intake based on expected wgt

+/- Feeding behavior modification Psychosocial involvement/ intervention Close follow up

Hospitalization when necessary

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Physical and cognitive delays

Summary: G.R.O.W.T.H.
Gather history and extensive physical Remember genetic contribution Only order basic labs in initial eval Wonder about zebras Track growth trends Hospitalize or hormonally treat
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Why Do We Have to Talk About it at All?

Personal
Depending on current status in app. 7, 19, or 31 months you will sit for the ABFM (13%-pediatrics) ACGME competencies / AAFP core recommendations Parental concerns

Patients

Cognitive development

Doc, is my baby growing right? Arch Dis Child. 2005 Sep;90(9):925-31. Epub 2005 May 12. J Child Psychol Psychiatry. 2004 Mar;45(3):641-54.

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Take Home
The keys to diagnosing FTT is finding the time to accurately measure and plot wgt/ht and then access the trend

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References
Listernick, R. (2004). Accurate feeding history key to failure to thrive. Pediatr Ann, 33:3, 161-9. Burgos, R., Jutte, D. (2000). Residents column: doctor, is my child growing ok?. Pediatr Ann, 29:9, 585-7. Krugman, S., Dubowitz,H. (2003). Failure to thrive. American Fam Phy, 68:5, 879-84. Schwartz, R., Abegglen, J. (1996). Failure to thrive: an ambulatory approach. Nurse Pract, 21:5, 19-31. Careaga, M., Kernder, J. (200). A gastroenterologists approach to failure to thrive. Pediatr Ann. 29:9, 558-67. Bassali, R., Benjamin, J. (2004, August 11). Failure to Thrive. eMedicine. Retrieved September 17, 2005, from http:///www.emedicine.com/ped/topic738.htm.

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