Failure to thrive

1. Failure to thrive Diagnostic criteria and diff dx H and P key points Dx testing in the evaluation

2. 18 month female difficulty gaining weight • 2 previous visits, noted to have slowing in her weight gain • Weight previously followed 75% slipped to 50 th • This visit wt below the 5 th percentile for age • Ht has continued along the same 50 th % trajectory

3. Scope of the problem • FTT used to describe children with poor growth; serial measurements of wt, ht, ofc compared with population growth averages • Growth over time helpful; constitutional delay children may grow consistently below (but parallel) curves • Wasting refers to deficit in wt to ht or type 1 FTT

4. The broad criterion • Decrease in wt, ht or ofc percentiles that crosses 2 major trajectories in downward trend • Weight for length below the 5th percentile (in absence of serial measurements) • Decreased mid-arm circumference-to-head circumference ratio • Weight below the 5 th percentile

5. Non-organic causes • Family dysfunction (divorce, spousal abuse, chaotic family style) • Parental dysfunction (psychosis, drug or alcohol abuse) • Parent-child interaction dysfunction • Isolation or lack of support (no family or extended family) • Lack of preparation for parenting or ignorance • Child abuse/neglect • Unusual food fad diet

6. Organic causes of FTT • Decreased caloric intake poor feeding (neuro/feeding disorders) decreased appetite (chronic disease) vomiting (gerd, ps, icp) chronic infection (giardea,etc) mucosal abnormalities (celiac, ibd) pancreatic insufficiency (cf, etc) enzyme deficiencies allergic gastroenteropathy

7. Increased losses and metabolic disorders protein losing enteropathy metabolic disorders bile salts def lympangiectasia Increased caloric requirments Hyperthyroidism Chronic diseases: chd, chronic resp disease, malignancy, ibd, immunodeficiency Furthermore

8. With apologies for the list • Parents and child interact warmly in office • Family hx noncontributory • Diet reasonably varied, good quantity • Parents are stable, good mental health, no drugs or abuse suspected

9. History and physical • Gives direction to the work; AJDC study of details the futility of investigations unless suggested in the h and p evaluation • 3 day diary always helpful in the history to corroborate the adequacy of caloric intake • Stool consistency may indicate malabsorption (malodorous, foamy, floating for fat malabsorption) • Vomiting hx directs toward broad differential

10. Physical exam • Malnutrition: hair texture and color, skin • Respiratory: lung sounds, clubbing • Heart disease: murmurs, PMI heave, sweaty babies • GI dis: inc L/S, perianal disease, guiac • Neuro: wasting, abnl tone

11. The history continues • Parents report pt is comfortable, 3 loose stools a day • FT, SVD, 3750 gm. • Breast to 6 months then formula; baby foods at 5 months; good mix of table foods • No sig infections, no hosp • Northern european descent; neg fam hx

12. The asthenic toddler • Thin child in no distress • General exam is normal • Abdomen is soft nontender; perhaps slightly distended • Neuro reveals interactive child, wiry, nml tone, nml reflexes

13. The 3 days diary gives detailed account of foods and milk Look for excessive fluid intake, inappropriate milk or juice intake Basic labs: CBC, ESR, chem 7 (bun/cr, CO2), TPro As indicated: stool fat, occult blood, white cells, O&P or elisa for giardia As indicated: sweat, HIV, TB skin test

14. H & P: loose stools?? • The loose stools raises suspicion for infection and/or malabsorption • Stool for O & P, elisa giardia, fecal fat, white cells • Sweat chloride and celiac antibodies

15. Los resultados • Celiac panel is positive • Transglutaminases (if ordered) 195 units (0-20 nml range) • Antiendomysial antibody is pos at 1:40 (nml less than 1:20)

16. Celiac disease • Production of local and systemic antibodies • Ig A antireticulin Ab and IgA antiendomysial Ab are specific markers for celiac disease • Tissue transglutaminase Ab has recently been identified as the autoantigen recognized by endomysial Ab (most sensitive marker)

17. Referral to GI • Esophagogastroduodenoscopy • Bx of small bowel consistant with celiac disease

18. Celiac disease • Intolerance to gluten of wheat, barley, rye, and oats • More common in whites, nearly nonexistent in Africa, Asia • 1:300 in western Ireland, 1:5000 in Minnesota, 2 % in Sweden and 1 in 50 in a high risk population (GI clinic waiting room)

19. More?? • Familial tendency follows polygenic inheritance • Strong association between celiac dis and HLA antigens • Interaction between genetics and environmental exposure • Wheat gluten is water insoluble protein left after starch extraction • Gliadin, a complex protein, is a fraction of the wheat gluten • T cell response to gluten in the lamina propria

20. Utility of endoscopy and Bx • Small bowel mucosal flattening • Lymphocytic infiltration in lamina propria, elongation of the crypts, villous atrophy

21. Treatment of Celiac • Mainstay is avoidance of gluten • Quite difficult to achieve in typical Western diet • Catch up growth can be rapid and complete in 15 months after effective avoidance

22. Sweaty babies • 10 week old male with poor weight gain • Sweaty babies suggests adrenergic overdrive • Gallop rhythm, heavy PMI • Liver edge is down • Radiograph of chest

23. 6 month comes pale and below 5 th percent • Renal lesions are “occult” • Bilateral abdominal masses • Cr 5.8 • Posterior urethral valves

24. Is it a real condition? • 15 month old female falls off the curves • CO2 12 on first determination; 15 on repeat • Proximal absorption defect seen in toddler years • Responds to large doses of bicarb (10 per kg divided) • Appetite improves and weight gain is seen

25. Newborn screening • 6 month old comes in with weight down • She appears puffy • Rsv then chronic congestion • T Pro depressed • False negative from NB screen