Susan Schayes M.D.

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Failure to Thrive

• Susan Schayes M.D.
• Emory Family Medicine
• Emory SOM

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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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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

• 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

• 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
  gt1 occasion
• Ht or Wgt falling 2 major percentiles
• Below 10th percentile for ht/wgt
• lt 80 of ideal body wgt for age
• Head circumference important, but not part of FTT
  entity

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OK135S053
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OK135S054
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OK135S055
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OK135S056
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Selective Differential Dx

• Inadequate caloric intake
• Inadequate absorption
• Increased metabolism
• Defective utilization

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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

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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)
• Double by 4 months, triple by 12
• Grow 25 cm in length during 1st year
• Make sure you have the right chart
• Premature
• Breastfeeding
• Ethnic
• Down Syndrome
• www.cdc.gov/growthcharts

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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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Normal Growth

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Organic causes of FTT

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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.

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IEM

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

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IEM ?Associations

• Odors -
• 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

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FTT

• Physical
• Gomez Criteria- comparing the current expected
  weight for age 50 percentile
• lt60 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
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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
• Physical and cognitive delays
• Hospitalization when necessary

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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
• Patients
• Parental concerns
• Doc, is my baby growing right?
• Cognitive development
• Arch Dis Child. 2005 Sep90(9)925-31. Epub 2005
  May 12.
• J Child Psychol Psychiatry. 2004
  Mar45(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, 333,
  161-9.
• Burgos, R., Jutte, D. (2000). Residents column
  doctor, is my child growing ok?. Pediatr Ann,
  299, 585-7.
• Krugman, S., Dubowitz,H. (2003). Failure to
  thrive. American Fam Phy, 685, 879-84.
• Schwartz, R., Abegglen, J. (1996). Failure to
  thrive an ambulatory approach. Nurse Pract,
  215, 19-31.
• Careaga, M., Kernder, J. (200). A
  gastroenterologists approach to failure to
  thrive. Pediatr Ann. 299, 558-67.
• Bassali, R., Benjamin, J. (2004, August 11).
  Failure to Thrive. eMedicine. Retrieved September
  17, 2005, from http///www.emedicine.com/ped/topic
  738.htm.