when simple and natural gets complicated failure to thrive
TRANSCRIPT
When Simple and Natural Gets Complicated
Failure to Thrive
“I’m a Failure to Mother”
• Be careful of pejorative language – Parental Deprivation Syndrome (1960)
• Primary need is to instill confidence in the family
“I’m a Failure to Mother”
“Growth Deficiency”
• Weight based assessment
• Insufficient growth velocity
Weight
Height
Head Circumference
• Organic/Inorganic
Start at the Beginning
Uteroplacental Insufficiency
Maternal Hypertension
Diabetes Mellitus
Renal Disease
Collagen Vascular Disease
Genetics
Parental - Age
Fetal – Trisomy, Russell-Silver Syndrome
Maternal Nutrition - time dependant, relatively resistant
Start at the Beginning
40% of Growth Deficient infants
are born with birth weights of less than 2500 grams (5 pounds 8 ounces)
Start at the Beginning
During fetal period, endocrine system has little impact on growth.
Pituitary aplasia, congenital hypopituitarism or growth hormone insensitivity will have NORMAL weight at birth
Normal Growth Variation
More than half of newborns experience an upward shift of growth during the first 3 months
30% of normal babies experience a downward shift between the ages of 3 and 18 months
Children reach genetic length by 2 years
Many children have significant weight decrease around between 9 and 15 months
Timing of Abnormality
Severe Anatomic Abnormality
Infection – GBS, TORCH
Breast Feeding Dysfunction
Cardiac Anomaly
Cystic Fibrosis
Milder Anatomic Abnormality
Severe Reflux
Protein Sensitivity
Deprivation
Chronic Reflux
Inappropriate Diet
Heavy Metal Poisoning
Birth 1 week 2-4 weeks 1 month 6 months 9 months 1 year
Causes of Failure to Thrive
Inadequate Input
Excessive Output
Increased Utilization
Humans are a Closed Energy System
textCALORIES IN
-METABOLIC USE
-CALORIES LOST/
NOT USED=
ZERO
Causes of Failure to Thrive
Inadequate Input
Excessive Output
Increased Utilization
Inadequate Input
1. INSUFFICIENT NUTRITION OFFERED
2. MATERNAL/CHILD AXIS DYSFUNCTION
3. PSYCHOSOCIAL DYSFUNCTION4. SEVERE GASTROESOPHAGEAL
REFLUX / VOMITING5. MECHANICAL PROBLEMS6. SUCKING OR SWALLOW
DYSFUNCTION
Inadequate Input
INSUFFICIENT NUTRITION OFFEREDMaternal Medical StressAnti-histaminesNarcotics/AlcoholInappropriate or incorrectly
constituted formulaDisplacement of nutritious offering
by poor nutritional component
Vitamin deficiencyLead (5-35 mcg/dL) potentiated by
poor Calcium and Vitamin D
Inadequate Input
MATERNAL/CHILD AXIS DYSFUNCTION
Inappropriate knowledge of infant/child diet
Sub-optimal feeding techniqueMaternal depressionPoor bonding (NICU, illness, maternal
aversion, abuse)
Inadequate Input
PSYCHOSOCIAL DYSFUNCTION25% of children in Tennessee live
below the poverty levelIn Chattanooga 80% of African-
American children are born to single mothers (poor social network)
Inadequate Input
PSYCHOSOCIAL DYSFUNCTIONMarital stressDomestic violenceParental employmentChildren of mother’s under 18
have poorer growth and twice as likely to be abused
Number and age of siblings/health of others in the family
Homelessness or home instability/unstable transportation
Inadequate Input
SEVERE GASTROESOPHAGEAL REFLUXPoor intake Pain feedback loop
VOMITINGInfectious gastroenteritis/post-vial ileusChronic pyelonephritisIncreased intracranial pressureCyclic vomitingPoorly controlled Abdominal migrainesAdrenal insufficiencyIpecac
Inadequate Input
MECHANICAL PROBLEMSCleft paletteMicognathia or MacroglosiaTight labial frenulumNasal obstructionIntestinal Obstruction
(Volvulus, Intusception, Hirschsprung’s,
Pyloric Stenosis)Chronic constipationAdenoidal hypertrophyDental lesions
Inadequate Input
SUCKING OR SWALLOW DYSFUNCTIONNeonatal Abstinence SyndromeCNS pathology (stroke, tumor,
hydrocephalus)Genetics Syndromes (Trisomy)Cardiopulmonary DiseaseNeuromuscular weakness/toneCerebral PalsyAnorexia of chromic infection, immune
deficiency, leadBehavioral (apathy or rumination)
Causes of Failure to Thrive
Inadequate Input
Excessive Output
Increased Utilization
Increased Utilization
CARDIAC DISEASE Congenital or Acquired
SEPSIS CHRONIC RESPIRATORY INSUFFICIENCY
Bronchopulmonary dysplasiaCystic fibrosis
RENAL DISEASEpartial posterior valves, severe reflux
with UTI, Renal Tubular AcidosisHYPERTHYROIDISM
Increased Utilization
CHRONIC/RECURRENT SYSTEMIC INFECTION
UTI, Tuberculosis, TORCHHIV – degree of viremia
correlates with poor growth
MALIGNANCYINFLAMMATORY BOWEL DISEASEDIABETES MELLITUSCHRONIC SYSTEMIC DISEASE
Juvenile Idiopathic Arthritis
Increased Utilization
Metabolic DiseaseInborn errors of metabolism
(normal infant that deteriorates with lethargy, poor feeding, convulsions, vomiting)
Storage diseasesHypercalcemiaAdrenal insufficiency
Causes of Failure to Thrive
Inadequate Input
Excessive Output
Increased Utilization
Excessive Output
Biliary AtresiaNecrotizing Enterocolitis or Short Bowel SyndromeMalabsorption
Lactose intolerance Cystic fibrosisCardiac disease Inflammatory bowel diseaseMilk/food allergy or irritation ParasitesCystic Fibrosis Celiac Disease
Infectious diarrheaRenal losses
Fanconi Syndrome Chronic renal insufficiencyVitamin D resistance Type I Diabetes Mellitus
Causes of Failure to Thrive
Inadequate Input
Excessive Output
Increased Utilization
Isolated Linear Growth Deficiency
Familial Intrinsic Short StatureChromosomal Abnormality
Trisomy 13, 18, 21
Chromosome 22 del
Gonadal Dysgenesis
(45, X)Skeletal Dysplasia
Endocrine DysfunctionPituitary
InsufficiencyHypothyroidismGH
deficiency/resistance Younger children
Hypophosphatemic
Rickets Older children
HypercortisolismPseudohypo-
parathyroidism
Isolated Linear Growth Deficiency
Management Tips
•If clinically and socially stable, give yourself time and use frequent observational follow up•Even if clear organic cause evident do not forget about psychosocial components – most organic causes have mixed non-organic component•Be clear with family about seriousness of child’s status
–insist they be seen–“Ring the Bell” - get all hands on deck
Management Tips
•Look the grandmothers in the eye, get them on your side, ask them what they think is wrong and give them jobs•Ask all important members of the team for their assessment and theories on treatment•Normalize familial expectations•Access parental dietary attitudes
–Unhealthy, sweet, hot/cold foods, fattening, food allergy
Management Tips
•Ask every time you meet with the family–Diet
•“What are you feeding the child?”–Caloric Intake
•“What exactly did your child eat in the last 24 hours?”
–Eating Environment•“How are you feeding the child?”
–“What do you Think about your child’s feeding”
Expected Daily Weight Gaingrams/day
0 to 3 months 303 to 6 months 186 to 9 months 129 to 12 months 91 to 3 years 8
“Catch Up” weight gain is two to three times greater than average for age
Calculating Calorie Need
Dietary Reference Intake (kcals/kg/day)0 to 6 months 1086 to 12 months 981 to 3 years 102
“Catch Up” calorie calculation 150% DRIAlternative method(DRI x median weight for length)/actual weight
Basal Intake Rate for Protein
2.2 grams/kg per day
Other Considerations
• Calculated calorie requirements are estimates. Severe failure to thrive may require greater than 200kcal/kg• Target calorie intake should be achieved over 5-7 days• Malnutrition is usually associated with some degree of anorexia• High calorie feedings are hyperosmolar and may lead to diarrhea or malabsorption• Rapid refeeding may lead to hyperkalemia or
hypophosphatemia
Vitamin and Mineral Supplementation
•ZINC–No reliable lab assessment–Baseline addition
•IRON–If Hemoglobin, Hematocrit or MCV labs indicate further work up add to diet
Feeding Strategy
• Start with small quantities and advancing as tolerated• Pushing feeding further apart• Assisted feeding to help caregiver
recognizing and responding to cues of hunger and satiety, identify
active feeding• Monitoring latch quality and persistence of latch
Increasing Milk Caloric Content - INFANTS
•Breast Milk–22 kcal/oz: add ½ scoop of formula to 4 ½ ounces–24 kcal/oz: add 1 scoop of formula to 5 ounces
•Formula–22 kcal/oz: add 2 ½ scoops of formula to 4 ½ ounces of water–24 kcal/oz: add 3 scoops of formula to 5 ounces of water
Increasing Milk Caloric Content - CHILDREN
•Increase calorie content of foods child likes to eat–Adding rice cereal to pureed foods–Replacing milk with high calorie substitutes–Limiting low nutrition liquids–Adding cheese, butter, sour cream, peanut butter to fruits and vegetables–Total energy and protein is more important than variety
Increasing Milk Caloric Content - CHILDREN
Increasing Caloric Density of Foods for Toddlers
Other Recipes
• 8 ounces of whole milk plus 2 Tbsp nonfat dry milk powder = 24 calories/ounce• 8 ounces of whole milk plus 3 Tbsp nonfat dry milk powder = 28 calories/ounce• 1 cup of whole milk, 1 package of instant breakfast and 1 cup ice cream = 430 calories
Adequate Response
• With adequate caloric and protein intake, “Catch Up” growth is initiated in 2 to 14 days• 4-9 months of accelerated growth must be maintained to restore a child’s weight to height• “Catch Up” height may lag behind weight by several months
Medical Appetite Stimulation
Cyprohepatidine has no proven long-term benefit
Lemons PK, Dodge NN. Persistent failure-to-thrive: a case study. J Pediatr Health Care 1998; 12: 27.
Indications for Hospitalization
•Severe malnutrition•Significant dehydration•Serious medical problems•Psychosocial risk to child•Failure to respond to outpatient
management•Precise documentation of caloric intake•Extreme parental impairment or anxiety•Severely disrupted parent-child axis•Family issues make outpatient therapy impractical
Supplement Oral Feedings
•Severe malnutrition that is not achieving adequate catch up in 4 to 6 weeks consider nasogastric feedings•Discontinue when consistent weight gain has been shown for 4 to 6 months•If weight gain remains inadequate after 3 to 4 months of nasogastric feeds gastrostomy tube may be appropriate
Frequent Follow Up
•Weekly follow up should continue until solid baseline growth is demonstrated
•Use ancilary team members for observation–Home health nurse–WIC–Dietitian
Refeeding Syndrome
•Sweatiness•Hyperthermia•Hepatomegaly – increased glycogen deposition•Widening of the cranial sutures- brain
growth faster than the skull•Increased periods of sleep•Fidgetiness or hyperactivity
Refeeding Syndrome
•Follow Potassium and Phosphorus in the acute period of reinstating nutrition•Initial intracellular ion shifts my cause
–Hypokalemia–Hypophosphotemia
•Can produce serious arrhythmias and muscle weakness
Can laboratory studies help diagnosis and management?
Can laboratory studies help diagnosis and management?
Not UsuallySills et al (1978) 2607 laboratory tests were undertaken for the entire study group of 185 children hospitalized for failure to thrive.
Only 36 (1.4%) of tests were of positive diagnostic significance. All of them were in the 34 patients whose diagnosis was strongly suggested by history and examination.
Homer et al (1981)82 children hospitalized for failure to thrive. History and examination was most sensitive indicator of organic disease.
Berwick et al (1982)122 infants hospitalized for failure to thrive.
Only 0.8% of tests were of positive diagnostic significance and 3.8% contributed to management. GI related labs were most helpful but indication for labs usually appearant in history and examination.
How can laboratory studies help?
•Infection or chronic inflammation •Electrolyte irregularity and monitor for refeeding impact•Iron deficiency•Vitamin deficiency(B12 or folate)•Nutritional status (albumin and prealbumin)•Fat soluble vitamins (ADEK)•Evaluate signs of specific disease
–Cystic Fibrosis–Metabolic Disease
How can laboratory studies help?
ELECTROLYTE IRREGULARITY AND MONITOR REFEEDING IMPACT
Hypernatremic hypovolemiaPoor fluid volume from feeding
HyponatremicUnmanageble free water volumeRTAHyperaldosteronism
HypomagnesiumStool loses
Hypokalemia/Hypophosphatemia
How can laboratory studies help?
IRON DEFICIENCYMost common nutritional deficiency in
childrenLabs Mean Corpuscular Volume
Serum Iron Plasma Ferritin
sensitive but also an acute phase reactant
Total Iron Binding Capacity, Transferrin
Ususally associated with hypochromic, microcytic morphology
How can laboratory studies help?
WATER SOLUBLE VITAMIN DEFICIENCY
Macrocytic AnemiaSerum B12 and Folate levels can be
directly measured
FAT SOLUBLE VITAMIN DEFICIENCYVitamin A, E and 25-hydroxyvitamin D can
be measuredProthrombin Time is a good proxy measure
of Vitamin K
How can laboratory studies help?
EVALUATING NUTRITIONAL STATUS Prealbumin
Synthesized in liverHalf-life 2 daysExquisitely sensitive to adequate
levels of protein and energy intake
Low levels in children <13, neonates <4
AlbuminSynthesized in liverHalf-life 14-20 days so reflect last
three weeks of nutritionBe careful with large protein losses
from circulationAscites, Renal disease, GI
losses
How can laboratory studies help?
Cystic FibrosisStool for fecal fat or trypsinogen
Other causes of malabsorptionStool for reducing substances (carbohydrate
enzyme deficiencies)
Celiac DiseaseAntibody Screening (Celiac Panel)
Endocrine DysfunctionGrowth hormone, IGF1, IGFBP3, TSH, free T4Rule out if height above 50th percentile
How can laboratory studies help?
ZINCSerum Zinc level have a high degree of
variation through the dayAssume Zinc deficiency in malnutrition/growth failure
Long Term Considerations
Systematic review of cohort studies shows
Decreased IQ of questionable clinical significance
Height and weight seem to be lower percentiles
Psychomotor and educational outcomes seem to be
lower than population norms
• Child with no serious congenital anomaly or confirmed genetic disorder
• Greater than 5 organ symptoms involvement• Multiple presentations to previous institutions
for evaluation• Long and convoluted history with multiple
identifying features as treatment adherence failure leads to next subspecialty evaluation
• Refusing feeding team evaluation, home evaluation or changing/adding formula/supplement without medical consult
• History of maternal pregnancy complications
• Three of more parental-reported allergies
Red Flags for Medical Child Abuse in Growth Deficiency
References
•Berwick DM et al. Failure to Thrive: Diagnostic Yield of Hospitalization. Archives of Disease in Childhood. 1982; 57: 347-351.•Bithoney WG, Dubowitz H, Egan H. Failure to thrive/growth deficiency. Pediatric Rev 1192; 13: 453.•Ellerstein NS, Ostrov BE. Growth patterns in children hospitalized because of caloric-deprivation failure to thrive. Am J Dis Child 1985; 139: 164.•Frank DA. Failure to thrive. In: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 3rd ed, Augustyn M, Zuckerman B, Caronna EB (Eds), Lippincott Williams & Wilkins, Philadelphia 2011. p.204.•Frank D, Silva M, Needlman R. Failure to thrive: Mystery, myth and method. Contemp Pediatr 1993; 10: 114.•Frank DA, Zeisel SH. Failure to thrive. Pediatr Clin North Am 1988; 35: 1187.•National Research Council, Food and Nutrition Board. Recommended Daily Allowances. National Academy of Sciences, 10th ed, National Academy Press, Washington, DC 1989.•Goldbloom RB. Growth failure in infancy. Pediatr Rev 1987; 9: 57.•Grey V, Landis L, Pall H, Drury D. Monitoring of 25-OH vitamin D levels in children with Cystic Fibrosis. J Pediatr Gastroenterol Nutr 2000; 30: 314.•Haynes CF, Cutler C, Gray J, Kempe RS. Hospitalized cases of nonorganic failure to thrive: the scope of the problem and the short-term lay health visitor intervention. Child Abuse Negl 1984; 8: 229.
References
•Homer C. et al. Categorization of Etiology of Failure to Thrive. American Journal of the Diseases of Children. Sept 1981; 135: 848-851.•Ingenbleek Y, Young V. Transthyretin (prealbumin) in health and disease: nutritional implications. Annu Rev Nutr 1994; 14: 495.•Jafee AC. Failure to Thrive: Current Clinical Concepts. Pediatrics in Review 2011; 32: 100.•Lemons PK, Dodge NN. Persistent failure-to-thrive: a case study. J Pediatr Health Care 1998; 12: 27.•Mash C, Frazier T, Nowacki S, Worley S, Goldfarb J. Development of Risk-Stratification Tool for Medical Child Abuse in failure to Thrive. Pediatrics 2011; 128; e1467.•Maggiono A, Lifshitz F. Nutritional management of failure to thrive. Pediatr Clin North Am 1995; 42: 791.•MacLean WC Jr, Lopez de Romana G, Massa E, Graham GC. Nutritional management of chronic diarrhea and malnutrition: primary reliance on oral feeding. J Pediatr 1980; 97:316.•Measurement of visceral protien status in assessing protein and energy malnutrition: standard of care. Prealbumin in Nutritional Care Consensus Group. Nutritional Care Consensus Group. Nutrition 1995; 11:169.•Rudolf M, Logan S. What is the long term outcome for children who fail to thrive? A systematic review. Arch Dis Child 2005; 90: 925-931.•Schmitt BD, Mauro RD. Nonorganic failure to thrive: an outpatient approach. Child Abuse Negl 1989; 13: 235.
References
•Seres DS. Surrogate nutritional markers, malnutrition and adequacy of nutrition suppot. Nutr Clin Pract 2005; 20: 308.•Sills RH. Failure to Thrive. The Role of Clinical and Laboratory Evaluation. American Journal of Diseases of Children. Oct 1978; 132: 967-969.•Smith DW, Truog W, Rogers JE, et al. Shifting linear growth during infancy: illustration of genetic factors in growth from fetal life through infancy. J Pediatr. 1976;89:225-230•Swartz I. Failure to Thrive: An Old Nemesis in the New Millenium. Pediatrics in Review 2000; 21: 257.•Tougas L, et al. Dietary Manual, Department of Nutrition. Boston, MA: Children’s Hospital; 1991•Walravens PA, Hambridge KM, Koepfer DM. Zinc supplementation in infants with a nutritional pattern of failure to thrive: a double-blind, controlled study. Pediatrics 1989; 83: 532.•Wright CM. Identification and management of failure to thrive: a community perspective. Arch Dis Child 2000; 82: 5.•Zenel JA Jr. Failure to thrive: a general pediatrician’s perspective. Pediatr Rev 1997; 18: 371.