Failure to Thrive Competency: Case:

Transcription

1 Failure to Thrive 1 Competency: The resident should be able to define normal growth as well as failure to thrive, complete a thorough history, develop a differential diagnosis, differentiate between organic and nonorganic FTT, and implement a course of management. Case: Pt is an 8 wk old male infant who presents to your clinic for the first time with a complaint of cough and repeated emesis for 4 wks. Mother reports frequent gagging, coughing, and arching with and without feeds. Feeds include Isomil 2oz Q3hr. Mom also states that the child spits up all his food with 5-8 episodes of emesis per day, non-bilious and non-bloody. Mother also informs you that the pt has repeated crying episodes in the evening and is unable to be consoled. No rash, no fevers, no cyanosis, no diarrhea, no stiffening, and no jerking episodes. PMHx: 6 wks of age for parainfluenza ALL: NKDA Meds: Nystatin PO for thrush Birth Hx: Born at 38 OSH to a 17 y/o G1P1. Per mom there were no complications with the pregnancy. Denies GDM, HTN, and infections. Denies GC/Chlam and HSV. Unknown GBS status. Birth wt was 6lbs 2 oz. Baby was discharged home with mom in <48hrs. No complications per mom. Developmental: pt is unable to hold head up past 45 degrees, does not track, does not smile. Social: Lives with 17 y/o mother. +tobacco exposure. Mom is the child s primary care giver. FOB is not involved. Mom denies support from her own friends and family. Mom dropped out of HS and is currently not working. Physical Exam: Wt: 3.4KG <5% HT:53cm 5% HC: 37.5 cm 5% General: Small, thin infant HEENT: NC/AT, no temporal wasting, AFOSF, white sclera, +RRxB, EOMI, PERRL, nares patent, nml set ears, no pits/tags, nares patent, +MMM, scant thrush buccal mucosal. PULM: CTA xb, nml resp effort CV: RR s murmur ABD: soft, NT, ND +BS no masses GU: nml male, +circ Spine: intact no tuffs, no dimples Neuro: nml tone, +grasp x4, +suck Questions: 1. What is normal growth? 2. Most common cause of irregular growth curves? 3. What is the definition of failure to thrive? 4. Classify failure thrive 5. What aspects in the history should be addressed? 6. What lab work should be obtained? 7. What treatment options are there? 8. Should the patient be hospitalized? 9. What are the long term complications of FTT?

2 Overview: Some articles quote that FTT accounts for 1-5% of pediatric hospital admission. National surveys state that as many as 10% of children seen by there PMD have signs of growth failure. FTT is a common sign and remains a diagnostic and therapeutic challenge. What is normal growth? Term infants lose 5-10% of their birth weight initially but regain it by 7 to 10 days of age. They double their birth weight by 4-5 months and triple it by 1 year. Height should double by 3-4yrs. During the 1 st 3 months of life infants should gain 25-30g per day. During 3-6 months, infants should gain 20 g/day and by 6months to 1 year of age, 12g/day. Caloric requirements are 108 kcal/kg/day for infants 0-6 months of age, 98 kcal/kg/day 6-12 months, 102 kcal/kg/day for children 1-3 years of age, 90kcal/kg/day for 4-6 years of age, and 70 kcal/kg for 7-10 years of age. Premature infant usually require kcal/kg/day. What is the most common cause of irregular growth curves? Errors in taking or plotting measurements. Measuring height: infants should be measured on a length board and in children older than 36 months a stadiometer should be used. Head circumference: measure just above the eyebrows, just above the ears, and across the most prominent part of the occiput. What is the definition of Failure to Thrive? Failure to Thrive is a sign of unexplained weight loss or poor weight gain in a child or infant. There are three distinct criteria: 1. A child younger than 2 years of age whose weight is less than the 3 rd or 5 th percentile for age on more than one occasion. 2. A child younger than 2 years of age with weight is less than 80% of the ideal weight for age. 3. A child younger than 2 years whose weight for age percentile crosses two major percentiles lines on a standard weight curves below a previously established growth rate. Exceptions to the definition: There are some exceptions to the above criteria: child with genetically short stature, SGA infants, Preterm infants, and over-weight infants whose height gain exceeds weight gain. Preterm infants should be plotted using there corrected age until 2 years of age for children born >1,000g and until 3 years for children born <1,000g. Special growth charts should be used for the following conditions: Trisomy 21, Prader-Willi, Williams syndrome, Cornelia de Lange, Turner, Rubinstein-Taybe, Marfan, and Achondroplasia. 2

3 Classifying failure to thrive Historically, FTT has been divided into organic and inorganic causes. Organic causes being major disease processes or organ dysfunction and classically represent 30% of all FTT. Whereas non-organic FTT is due to insufficient emotional or physical nurturing, accounting for 70%. However, FTT is now considered a spectrum of organic and inorganic causes. Organic causes Nutritional o Insufficient caloric intake o Kwashiorkor o Marasmus o Zinc/iron deficiency Gastrointestinal o Feeding disorders: oral motor apraxia, oral aversion, oral/esophageal abnormalities, cleft palate, poor dentition o Vomiting: reflux, pyloric stenosis, structural anomalies o Diarrhea: chronic infant/toddler diarrhea, infectious diarrhea o Malabsorbtion: CF, IBD, Celiac disease, short gut, pancreatic disease, o Hepatic: chronic hepatitis, biliary disease, glycogen storage disease Infectious Disease: o acute infections o chronic: TB, HIV, parasites, congenital immunodeficiency Cardiac o Congenital heart disease Pulmonary o Obstructive: Tonsillar hypertrophy, OSA o Asthma o BPD o CF Renal o Chronic pyelonephritis o RTA o Chronic renal insufficiency Endocrine o Hypothyroidism o Diabetes o Rickets o Growth hormone deficiency o Adrenal insufficiency Congenital o Chromosomal abnormalities o Gonadal dysgenesis o Inborn errors in metabolism CNS o CP o Pituitary insufficiency o Diencephalic Syndrome o Lead toxicity 3

4 Non-organic causes Lodging: homelessness, shelter, transportation Family dysfunction: marital stress, mental illness, substance abuse, history of child abuse Child maltreatment: physical abuse, intentional/non-intentional neglect 4 What aspects in the history should be addressed in FTT? Most studies indicate that the organic cause of FTT can be discerned from the history and physical alone. History: past medical history including a complete ROS, diet history, family history, psych history. ROS: should include questions of emesis and stooling habits, as well as changes in activity level, and behavior. Diet history should include a record of a typical feeding schedule, plus food preparation (formula prep, portion size), methods of feeding, length of time spent feeding, and diet supplementation/medication. A prospective 3 day food record/calorie count including snacks and beverages should be performed. Parents should bring this back to the next office visit due to the fact that parental recall can be fairly inaccurate. A direct observation of parent and child interaction during a feed should occur. It should address issues of sucking ability, choking, regurgitation, vomiting, and diarrhea. Parents attitude about feeding and resources available for food (restrictions of food based on finances, religion, other) should also be addressed. Psychosocial history: Who are the major people in the child s life, major events in the child s life, family stresses including illness, martial stress/depression, domestic violence, substance abuse, employment, and financial obligations. Family history should include stature and growth patterns of siblings, parents, and grandparents. History of medical problems and genetic diseases. A complete physical exam should include accurate measurements of head circumference, weight, and length and plotted on appropriate growth charts. What lab work should be ordered? Excessive laboratory tests are not warranted. In a study by Berwick, only 0.8% of laboratory tests ordered for children with an unknown cause of FTT provided an abnormality that contributed to the diagnosis. In a second study, 185 patients were hospitalized for FTT and only 1.4% of laboratory studies were of diagnostic assistance. The laboratory tests and work-up completed should be guided by history and physical exam. Basic work-up may include CBC (for anemia), BMP with Magniusum (RTA, metabolic disease), TFTs, UA (renal and metabolic disease), ESR/CRP (sign of inflammation/infection), stool for fat, ph, reducing substances, occult blood, ova and parasites, sweat chloride, lead, TB and HIV. What treatment options should be utilized? For organic FTT, the clinician must determine and treat the underlying cause. For the majority of cases which are non-organic FTT, a multi-disciplinary approach should be utilized including a medical team, nutritionist, and a social worker. For inadequate caloric intake, catch up growth requirements estimates to be calculated by this equation 120 kcal/kg x (goal weight/current weight) With this formula, a child is expected to take times the normal requirements. This is unrealistic, so an attempt to create a caloric dense diet should be made. Formula should be fortified by adding glucose polymers, protein, and increased lipids. Vitamins including iron and Vitamin D may be

5 needed if signs of rickets or iron deficiency are present. Adding Zinc, 25 mg Q day, has been shown to enhance growth. Involve the family in the care of the patient, reinforce positive behavior, and provide encouragement and teaching. Eternal tube feeding or gastrotemy tube feeding can be considered in patients who do not achieve sufficient caloric intake. Pt s should be monitored closely for growth as well as re-feeding syndromes. Return visits to the clinic should initially be every 2-4 weeks and then progress to every 1-2 months. Studies have shown that catch up growth should occur within months. Reports to DCFS should be made if neglect or abuse is suspected such as in non-accidental injury, severe emaciation without seeking health care, hostile mother-child interaction, family that is unmotivated). Should your patient be hospitalized? A majority of the work-up can be performed as an out-patient. A study performed by Berwick et al showed the diagnostic yield of hospitalization was not costeffective. However, hospitalization may be required for severe malnutrition, which is seen when weight is <60% of ideal, or if hypothermia, bradycardia, or hypotension is present. It may also be used to evaluate parent-child feeding interaction. It can also be used to document weight gain with the proper caloric intake. Hospitalization should definitely be utilized if abuse or neglect is suspected, or lack of catch-up growth following out-patient management. What are the complications? Acute risks include risk of infections and developmental delay. The long term complications of FTT are controversial, but may include insecure attachments, impaired cognitive abilities, and future behavioral problems. It is know that children with the non-organic FTT are more likely to suffer these complications. One study found that 1/3 of the children with psychosocial FTT had developmental delay and behavior/social problems. 5 References: Behrman, R., et al. Nelson s Texbook of Pediatrics. 14 th edition Kane, M, MD, MPH. Pediatric Failure to Thrive. Clinics in Family Practice. June 2003; 5(2) Schecter, M, MD, Adam, H, Weight Loss and Failure to Thrive. Peds in Review. July 2000; 21(7) Schwartz, I., MD. Failure to Thrive: An old Nemesis in the New Milennium. Pediatrics in Review. August 2000; 21(8) Zenel, J, MD. Failure to Thrive: A General Pediatrician s Perspective. Pediatrics in Review. November 1997; 18(11) Author: Laura Uselding, M.D. Reviewer: Tamara Nix, M.D.