Pediatric Failure to Thrive

1. Pediatric Failure to Thrive Michael Michener, MD Major, USAF 14 March 2007

2. Overview Definitions Case presentation Introduction Diagnosis Treatment Outcomes Top 6 things to remember about FTT

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

4. Case Presentation 4 mo F, well child visit (Sept 06) Mom complained about poor wt gain Same problem with first child Husband deployed Parents small stature Other development was normal Mom alleged that feeding was going well (breastfeeding) Wt = 10 lb 8 oz

5. Case Presentation Went to ER at age 5 months Wt was �down 1 lb� Infant transferred to a childrens hospital for inpatient stay Infant refusing to breast or bottle feed NG tube placed 4oz q4 hours OT working with baby to help with feeding

6. Introduction Failure to thrive (FTT): A sign that describes a problem rather than a diagnosis Usually 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 of up to 25%, then follow a normal curve -- this is not failure to thrive

7. Introduction Specific infant populations- Premature/IUGR � wt may be less than 5th percentile, but if following the growth curve and normal interval growth then FTT should not be diagnosed Modified growth charts exist for specific populations

8. Introduction Historically has been divided into organic and nonorganic causes Most cases have mixed etiologies This classification system is out of favor More useful classification system is: Inadequate caloric intake Inadequate fat or carbohydrate 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 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 *(SOR � C, expert and consensus opinion, Ref 1)

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. Physical Accurate measurement of child�s height, weight, head circumference Single data point has limited usefulness Evaluate for dysmorphic features Mouth, palate Neurologic exam Signs of spasticity or hypotonia Cardiovascular/Lung exam

15. Physical Signs of neglect or abuse Lack of age appropriate eye contact, smiling, vocalization, or interest in environment Chronic diaper rash Impetigo Flat occiput Poor hygeine Bruises Scars

16. 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?

17. Lab Evaluation Unless suggested by H&P, no routine lab tests recommended initially* One study of hospitalized pts resulted in only 1.4% of tests being of diagnostic assistance in FTT If problem persists, could consider: CBC, U/A, Electrolytes, TSH, ESR, Lead, HIV, Tb If not improving with adequate diet, consider: Stool for fat, reducing substances, pathogens Celiac antibody testing CF testing *(SOR � B, historical, uncontrolled study, Ref 1, 2)

18. Management 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 Assure access to WIC, food programs, other community resources

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

20. Management Parental behavior 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

21. Management Do you hospitalize? Rarely necessary Consider if: the child has failed outpt management FTT is severe Medical emergency if wt <60-70% of ideal wt Hypothermia, bradycardia, hypotension safety is a concern

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

23. Outcomes and Prognosis Persistent disorders of growth 6 of 7 studies showed statistically significant persistent poor growth (ht, wt, hc) in FTT group at up to 5 years from initial treatment. Earlier intervention leads to better outcomes

24. Outcomes and Prognosis FTT and Immunologic/Infectious Outcomes FTT children have significantly increased susceptibility to infection Among hospitalized children � increased rates of bacteremia and mortality Increased rates of upper and lower respiratory infections

25. Outcomes and Prognosis Concurrent Behavior disorders FTT groups scored lower on reports describing affect and communications skills Behavior disorders at follow-up Various trials have demonstrated significant increase in behavioral problems Cognitive Development There is a consistent association between FTT and lower cognitive development test scores in preschool and primary school children

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

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

28. Case Presentation�Follow-up Received NG tube feeds for approx 2 weeks OT worked with pt to find a nipple that she would take Wt gain rapidly picked up in late November

29. References 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 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&selectedTitle=6~29 version 14.2, april 2006:pgs 1-8. Krugman SD, Dubowitz H. Failure to thrive. American Family Physician, sept 1 2003. Vol 68 (5). Kane, ML. Pediatric Failure to Thrive. Clinics in Family Practice. Vol 5, #2, June 2003, pages 293-311. 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/ Bauchner, H. Failure to thrive, in Behrman: Nelson Textbook of Pediatrics, 17th ed, chapter 35, 36 - 2004. 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.