Growth Abnormalities

1
Growth Abnormalities

• Deviations in Physical Growth
• Debbie King
• 8805

2
Failure-to-Thrive (FTT)

• Definition
• No consensus on definition
• Descriptive rather than diagnostic term
• Generally refers to infants and young children
  whose weight is between the 3rd percentile on
  National Center for Health Statistics growth
  standards and/or whose weight trajectory has
  decreased by two major growth percentiles
• Traditional categories include organic FTT,
  nonorganic FTT, and mixed etiology FTT
• Newer categories include neurodevelopment FTT and
  social-emotional FTT

3
FTT

• Etiology/ Incidence
• Multifactorial etiology including underlying
  organic disease or predisposing medical
  condition, maladaptive parent-infant interaction,
  maternal depression, poverty, deficits in parent
  information and skills, child abuse and neglect
• Accounts for between 3 and 5 of all pediatric
  admission of all infants less than one year
• Male and females are equally affected

4
FTT

• Clinical Findings
• Inadequate intake
• Increased losses or decreased utilization
• Increases caloric requirements
• Altered growth potential
• Terms
• Wasting acute loss of weight or failure to gain
  at the expected rate or weight loss
• Stunting- reduction in height for age
• Marasmus- head circumference growth slow
• Kwashiorkor- significant protein deprivation may
  lead to insults like infection, may produce
  edematous malnutrition

5
FTT

• Differential Diagnosis
• Organic causes
• Gastrointestinal
• Cardiopulmonary
• Endocrine
• Infection
• Neurologic

6
FTT

• Social-emotional and environmental causes
• Maternal depression, isolation, marital
  difficulties
• Poverty/inadequate resources
• Inadequate resources
• Inadequate parenting knowledge and skills
• Difficult temperament
• Child abuse and neglect

7
FTT

• Diagnostic Methods/Findings
• History
• Identification of risk factors
• Height, weight, head circumference review
  longitudinal growth data, corrected for gestation
  age as appropriate
• Physical examination
• Feeding observation
• Home visit or public health nurse referral
• Laboratory assessment should be judicious based
  on history and clinical findings
• See FTT workup handout!!

8
FTT

• Management/Treatment
• Importance of developing therapeutic alliance
  with caregiver
• Usually managed on outpatient basis
• Interdisciplinary approach is optimal utilizing
  health care, nutritional, mental health and
  social service
• Provide caregivers with necessary information
  regarding nutritional needs of child and
  appropriate feeding skills to promote optimal
  growth
• Decrease fluid intake and increase solids!
• Close monitoring and follow-up on growth and
  development, social environment and
  interdisciplinary/ interagency communication
• May need referral to GI

9
Obesity

• Excess accumulation of body fat relative to lean
  body mass that results from excessive caloric
  intake relative to energy expenditure
• Operational definitions vary in literature
• Operational definitions of obesity in adults are
  derived from statistical data analyzing the
  association between body mass and the risk of
  acute and long-term morbidity and mortality

10
Obesity

• Etiology/ Incidence
• Multifactorial etiology
• Genetic predisposition and parental obesity(new
  studies very interesting)
• Dietary patterns
• Inactivity
• Cultural and familial food preferences
• Use of food as emotional buffer
• Physical disorders with decreased energy
  expenditure most prevalent nutritional problem in
  U.S.
• Childhood obesity prevalence is rising with
  current estimates 40 are overweight or obese
  depending on definition and cut-off values

11
Obesity

• Clinical Findings
• Parent and/or child concern regarding body weight
• Clinical observation of large size and/or excess
  fat on child
• NOTE- obese children become obese adults
• Childhood obesity predisposes to insulin
  resistance and type 2 diabetes, hypertension,
  hyperlipidemia, liver and renal disease, and
  reproductive dysfunction.
•  It also increases the risk of adult obesity and
  cardiovascular disease.

12
Obesity

• Differential diagnosis
• Endocrine dysfunction
• Congenital disorders/short stature
• Large frame
• Muscular hypertrophy
• Medication induced obesity

13
Obesity

• Diagnostic Tests/Findings
• History includes detailed dietary and activity
  level history, family history
• Physical examination, vital signs, blood pressure
• Anthropometric measurements
• Weight for height ration greater than 95th
  percentile on NCHS growth charts is commonly used
• Percent of ideal body weight greater or equal to
  120
• Skin fold thickness
• Body Mass Index- considered most useful(?)
• New NHANES III growth chart reference standards
  recently released

14
Obesity

• Management/ Treatment
• Prevention in infancy through parent education
  regarding nutritional needs and feeding
  strategies
• Discuss moderate modification of diet and caloric
  content while increasing exercise program
  (moderate exercise 3 times a week just as
  effective as heavy workout more freq)
• Goal for younger children is weight maintenance
• Occasionally weight loss

15
Obesity

• Behavior modification strategies directed at
  alternative coping measures to deal with stress,
  maintain motivation and reinforce regimen of
  success
• Involvement of family in therapeutic program
  increases likelihood of success
• Refer to collaborate with available community
  resources as appropriate
• http//www.medscape.com/viewarticle/701809?srcmp
  spon24uac134690DK
• Watch this prior to class and be ready for
  discussion

16
Anorexia Nervosa and Bulimia Nervosa

• Chronic and often severe disturbance in eating
  behavior accompanied by distorted perception of
  body weight, size and shape
• Anorexia Nervosa- eating disturbance associated
  with weight loss and refusal to maintain body
  weight at minimally normal level with subsequent
  amenorrhea
• Bulimia Nervosa- eating disturbance associated
  with episodic binge eating followed by
  compensatory efforts to prevent weight gain
• Anorexia may occur with or without binging
  bulimia may occur with or without purging

17
Anorexia Nervosa and Bulimia Nervosa

• Etiology/ Incidence
• Family enmeshment hypothesis
• Fear of sexual maturation
• Social pressure to be thin
• Ballet dancers and gymnasts at particular risk
• Associated with psychological profile of low
  self-esteem in spite of outward successfulness
• Both disorders are more common in females

18
Anorexia Nervosa and Bulimia Nervosa

• Anorexia affects approximately 1 of white
  middle/upper class females
• Bimodal distribution with one peak at 14 years
  and second at 18 years
• Bulimia is more common than anorexia with later
  age onset
• Suicide rates of 2 to 5 of those with chronic
  anorexia with all mortality as high as 10
• Normal to high intelligence, overachievers,
  perfectionists

19
Anorexia Nervosa and Bulimia Nervosa

• Clinical Findings
• Self-imposed weight loss
• Anemia, jaundice and secondary amenorrhea
• Vigorous exercise regimen to increase weight loss
• Constipation and reflux esophagitis
• Dry skin, brittle nails
• Lower body temperature, blood pressure and heart
  rate
• Sore throat, calluses on dorsum of fingers, loss
  of tooth enamel

20

• Screening questions
• How do you feel about your body
• Are there parts of your body you would like to
  change
• Do you see yourself as overweight, underweight or
  satisfactory
• If satisfactory has there been a time when you
  did not
• If overweight how would you change
• Have you ever been on a diet
• What have done to help yourself loose weight
• Do you count calories or fat grams
• Do you deep your intake to a certain number
• Have you ever used supplements or diet pills or
  laxatives
• Have you ever made yourself vomit

21
Anorexia Nervosa and Bulimia Nervosa

• Differential Diagnosis
• General medical condition
• Inflammatory bowel disease
• Diabetes
• Hyperthyroidism
• Malignancy
• Pregnancy
• Depressive disorder
• Substance abuse

22
Anorexia Nervosa and Bulimia Nervosa

• Diagnostic Tests/ Findings
• History
• Weight and height percentiles
• Mild- lt20 below IBM (ideal body weight)
• Moderate- 20 to 30 below IBW
• Severe- gt30 below IBM
• Physical exam
• CBC, serum albumin, glucose, electrolytes,
  thyroid function, ECG

23
Anorexia Nervosa and Bulimia Nervosa

• Diagnostic criteria
• Refusal to maintain body weight
• Intense fear of gaining weight
• Disturbance in the way ones own body shape
• In postmenarchal females amenorrhea for at least
  three cycles

24
Anorexia Nervosa and Bulimia Nervosa

• Management/ Treatment
• Interdisciplinary treatment plan
• Hospitalization for rehydration and re-feeding if
  condition warrants
• Refer to appropriate community resources for
  assessment tool, support, and education
• 25 poor outcomes regardless of intervention
• Very frustrating to treat!!

25
Anorexia Nervosa and Bulimia Nervosa

• Complications
• Early satiety
• Superior mesenteric artery syndrome
• Malnourished
• Constipation
• Osteoporosis- 50
• Mortality
• Cardiac
• Endocrine
• Metabolic
• Anemia
• Dehydration
• Acidosis, ect.
• Neurological
• Renal