Disclosures. Failure to thrive: The Growing Evidence. Outline. Handout Information. Definitions. Failure to Thrive: The Growing Evidence 2.

Transcription

1 Disclosures Failure to Thrive: The Growing Evidence We have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. Cathleen Lang, MD and Matthew Cox, M.D. University of Texas Southwestern Medical Center REACH Program Children s Medical Center Dallas Handout Information Case studies will be utilized to illustrate the discussion points Slides with patient information are not included in the handouts Outline Definitions Normal growth and development Mechanisms of malnutrition Dietary requirements Medical approach to FTT Differential diagnosis for growth failure Nutritional neglect Severe malnutrition Kwashiorkor, Marasmus, Psychosocial dwarfism Case Studies Definitions Failure to thrive: Used to describe infants and children who fail to meet standards for appropriate growth Weight is significantly lower than norms for age and gender Deficient growth over time Crosses 2 major percentile lines Gomez formula: Gomez formula Child s current weight Child s expected weight for age (50%) Used to assess degree of malnutrition <60% severe malnutrition 61 75% moderate malnutrition 76 90% mild malnutrition

2 FTT Facts 80% of cases involve infants < 6 months 95% of cases involve children < 2 years Mechanisms for Malnutrition Loss of calories through malabsorption / inadequate absorption Increased caloric expenditure (increased metabolism) Inadequate caloric intake Defective utilization of calories Inadequate absorption Inherited or acquired gastrointestinal conditions that result in inadequate growth despite appropriate calories Typically have abnormal stool character Smelly, bulky, greasy, bloody, or watery stools Fat Malabsorption Deficiency of fat soluble vitamins Vitamin A Vitamin D bone/calcium abnormalities Vitamin E Vitamin K bleeding predisposition Acquired coagulopathy due to clotting protein deficiency Steatorrhea fatty stools Inadequate caloric intake Psychosocial/behavioral factors that inhibit appropriate feeding Chaotic home environment Inadequate bonding Difficult breastfeeding Incorrect preparation of formula Parental stress, depression, substance abuse Inadequate caloric intake Other issues that may decrease intake Cleft palate Undetected oropharyngeal problems impairing suckswallow Brain injury Gastroesophageal reflux (GERD) If inadequate feeding continues, infant may fail to develop hunger satiety cues Decreased intake may become entrenched behavior Frank, et al. Ped Clinic North Am, 1988

3 Dietary Requirements Caloric Intake by Age Age Caloric intake (kcal/kg/day) Approximate calories (kcal/day) 0-6 months months years years years years female years male years female years male National Academy of Sciences Caloric Intake Needs to be adjusted for factors that may increase or decreased caloric need Physical activity Sedentary (typical daily living activities) Low active (30 60 minutes moderate activity) Active (60 minutes moderate activity) Very active ( minutes vigorous activity) Obesity Malnutrition (catch up growth) Chronic illness Age Expected Daily Growth Median Height Gain (cm/day) Weight gain range (grams/day) 0-3 months months months months months months years years Practical Expected Growth Age Height Gain (inches/month) Weight gain (lbs/month) 0-3 months ½ 4-6 months ½ 7-9 months 0.6 ¾ - 1 ¼ months ½ - 1 Medical Approach to Evaluation and Treatment months / 3-2 / months 0.3 ¼ - ½ 2-6 years ¼ - ½ 7-10 years / 3 -¾

4 Medical History Gather past medical records, prior growth points Dietary history Feeding environment Supervision, distractions, feeding positions Feeding behavior Distractibility, food refusal, early satiety Family history Social history Dietary History Volume taken Frequency Content Preparation Ready to feed, concentrate, powder Physical Examination Identification of dysmorphic features suggestive of genetic disease impeding growth Detection of underlying disease that may impair growth Assessment for signs of possible physical abuse Assessment of severity and possible effects of malnutrition Medical Exam Findings of Malnutrition General appearance Wasting Skin Rash, easy bruising Hair and nails Thinning of hair, spooling of nails Mouth Cheilosis, glossitis, bleeding Gastrointestinal Diarrhea Extremities Edema Neurologic Weakness, dementia, deficits Musculoskeletal Wasting, joint pain Treatment of Malnutrition Direct observation of feeds Infant Interaction of parent & child Feeding techniques and behavior Toddler Temperament Ability to focus during meals Food choices Emotional struggles with care giver Food refusal infantile anorexia Laboratory Evaluation Without specific evidence of organic disease, laboratory testing only helpful in 1.4% of cases (36/2607 lab tests) Standard lab tests Blood counts, kidney function, electrolytes, stool blood, stool reducing substances Specialty lab tests Inflammatory markers (ESR), thyroid function, sweat chloride, fecal fat ph probe, upper GI, Echocardiogram Chatoor, et al. J Amer Acad Child Adol Psych, Sills, RH. Amer J Disease Childhood, 1978

5 Specialist Evaluation Growth Failure Differential Diagnosis Feeding specialists Speech therapy Occupational therapy Gastroenterologists Endocrinologist Geneticists Multidisciplinary clinics HIV/AIDS Aspiration pneumonia Celiac disease Congenital heart disease Cystic fibrosis Cerebral palsy Chromosomal abnormality Diabetes insipidus Gastroesophageal reflux Genetic short stature Growth hormone deficiency Hypothyroidism Immune deficiency Liver disease Malabsorption Metabolic disease Pyloric stenosis Pulmonary problems Renal failure Renal tubular acidosis Sickle cell anemia Tuberculosis History Suggestive of Primary Medical Disease Process Difficulty initiating suck Sputtering or choking during feed Spitting up, vomiting, or signs of pain after feeding Early satiety Abnormal stools (watery, bloody, mucoid, foul smelling) Indicators of neurodevelopmental delay Sweating or difficulty breathing in infant Chronic or recurrent fevers HIV risk factors Esophageal Duplication Cyst Foregut remnant Lined with respiratory, enteric, gastric or squamous epithelium Mucosal tissue continues to secrete fluid leading to enlarging mass Treatment is surgical resection Failure to Thrive and Physical Abuse Nutritional Neglect Limited literature of co occurrence of fractures with FTT Consider skeletal survey or other imaging depending on history and examination No universal recommendations

6 Protein Energy Malnutrition Severe Malnutrition Deficiency of carbohydrates, proteins, fat, vitamins, and minerals Can cause compromised immune function, malabsorption Generally found in developing countries 6 51% of hospitalized children in developed nations with malnutrition Kwashiorkor Acute or chronic situation when protein deficits exceed caloric deficits Decreased protein stores Muscle wasting Edema Changes to skin and hair Weight may appear normal for height due to fluid retention Kwashiorkor Medical Treatment Nutrition Close monitoring Management of complications Infection Renal insufficiency Shock Vitamin and mineral supplementation Grover, Z and L Ee. Ped Clinics NA Kwashiorkor Devastating problem globally Predominantly seen in developing countries Defined as total body weight of 60 80% that expected for age and height with edema May have associated anorexia, diarrhea, increased susceptibility of infections In US, association with use of rice based substitutes (rice milk) or other food faddisms 1/6 of cases in US associated with poverty or social chaos Skin findings of diffuse fine reddish brown scaling resembling flaking paint Marasmus Develops after chronic and severe calorie deprivation Weight loss Marked wasting of fat and muscle stores Weight decreased more than height Heath and Sidbury. Current Opinions Pediatrics, 2006.

7 Refeeding Syndrome Metabolic and physiologic consequence of changes in glucose metabolism in patient with chronic caloric deprivation Chemical imbalances due to rapid electrolyte repletion, fluid resuscitation Low phosphorus, low potassium, low magnesium Increased glucose Clinical symptoms Paresthesias, weakness, mental status changes Cardiac dysfunction, diaphragm weakness Psychosocial Dwarfism Disorder of short stature of growth failure that is observed in association with deprivation, a pathologic environment, or both 3 types Type I infants FTT common, no GH deficiency Type II onset >3 years, bizarre behaviors, decreased GH Type III not FTT, responsive to GH Psychological disturbance is present Bizarre behaviors centered on food and water acquisition Sleep disturbances Abnormal behaviors (withdrawal, irritability, temper tantrums) Developmental delays Green, et al. Psychosocial dwarfism. J Am Acad Child Psych Case Studies for Discussion FTT Clinical Pearls Remember that medical and psychosocial causes of malnutrition often co exist Think about juice/water intake Multivitamin use Continued close medical follow up of the malnourished child is essential