FTT and PEM
Transcript of FTT and PEM
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FAILURE TO THRIVE
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BY :
ABDUL HAFIZ ALIAS060100846
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Definition
term is widely used to describe inadequate growth in early childhood
no consensus has been reached concerning the specific anthropometrical
criteria to define this description height or weight less than the third to fifth
percentiles for age on more than one occasion
height or weight measurements falling 2major percentile lines using the standard growth charts of the National Center for Health Statistics (NCHS) in a short time.
tr ue malnutrition (weight <80% of ideal body weight for age)
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Normal growth in term
infants
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Average birth weight for a term infant is 3
.3
kg. Average birth weight for a term infant is 3
.3
kg.
Weight drops as much as 10% in the first few days of life Weight drops as much as 10% in the first few days of life
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Weight/dayWeight/day g/dayg/day
00--3
3
mthsmths 2626--3
13
133--6 mths6 mths 1717--1818
66--9 mths9 mths 1212--1313
99--12 mths12 mths 99
11--3 yrs3 yrs 77--99
44--6 yrs6 yrs 66
Height/yrHeight/yr cm/yearcm/year
11st st 2525
22ndnd 12.512.5
44thth
-- onset onset of pubertyof puberty 55--66
PubertyPubertyonwardsonwards
1212
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Head Head
circumferencecircumference
(year )(year )
Average Average
(cm)(cm)
BirthBirth 3535
11stst
4747
22ndnd 4949
66thth 5555
upperupper--toto--lower bodylower bodysegment segment
ratioratio
Average(cm) Average(cm)
BirthBirth 1.71.7
11st st 1.31.3
77thth 1.01.0
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Normal growth in
premature infants
When plotting growth charts for premature babies, a "corrected age"should be used.
Corrected age : subtracting the number
of weeks of prematurity from the postnatal age Catch-up growth is attained, at
approximately age 18 months for head circumference, age 24 months for weight, and age 40 months for height,
then the normal growth charts can be used. In some premature babies with very
low birth-weight, catch-up growth does not occur until early school age.
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ETIOLOGY
NON ORGANIC ORGANIC COMBINATION
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NON ORGANIC
Poor feeding or feeding-skills disorder
Dysfunctional family interactions
Difficult parent-child interactions
Lack of support (eg, no friends, no extended family) Lack of preparation for parenting
Family dysfunction (eg, divorce, spouse abuse, chaotic family style)
Difficult child
Child neglect Emotional deprivation syndrome
Feeding disorders (eg, anorexia, bulimia)
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ORGANIC
Prenatal causes Prenatal causes Prematurity with complicationsPrematurity with complicationsMaternal malnutritionMaternal malnutrition
Toxic exposure in uteroToxic exposure in utero
Alcohol, smoking, medications, Alcohol, smoking, medications,
infectionsinfectionsIUGRIUGR
Chromosomal abnormalities Chromosomal abnormalities
Postnatal causes Postnatal causes Inadequate intakeInadequate intake
Poor absorption and/or use of Poor absorption and/or use of nutrients nutrients
Increased metabolic demand Increased metabolic demand
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COMBINATION
Chronic illness + social pressure
children with asthma, heart disease,
and CP all have or ganic reasons for
failure to thrive. In addition, the social pressures
(parental dysf unction, medications,
poor compliance) that children with
these conditions experience can cause behavioral changes that
result in decreased ener gy intake
and, therefore, failure to thrive.
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HISTORY
P
renatal history Smoking Alcohol consumption Use of medications Any illness during the pregnancy
Dietary history
how formula is prepared frequency of feeds, number of wet diapers and stools each day, and
a history of sequential weights type of food, meal frequency, and volume per feeding
Past medical history
illnesses that occurred since the neonatal period and signs of chronic conditions
Family and social history should include other siblings, living conditions, stressors, and data on parents' growth history
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PHYSICAL EXAMINATION Vital signs are usually within the reference range
Plot the head circumference, height, and weight on a growth chart
Growth charts should be evaluated for the pattern of failure to thrive
Edema Wasting
Hepatomegaly
Rash or skin changes
Hair color and texture changes
Mental status changes
Signs of vitamin deficiency
Irritability
Avoiding eye contact
Excessive sleepiness
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Failure of growth in weight, length, and head
circumference starting at birth, suggesting an
or ganic etiology that occurred in utero
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Growth failure in length and weight with a normal head
circumference in an infant with growth hormone deficiency.
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Constitutional delay of growth
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FTT secondary to caloric deprivation
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DIFFERENTIAL DIAGNOSIS
Child Abuse & Neglect: Failure to Thrive
Constitutional Growth Delay
Eating Disorder : Anorexia
Eating Disorder : Bulimia Fetal Alcohol Syndrome
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INVESTIGATIONS
CBC count
Urinalysis
Urine culture
Electrolytes, including
creatinine and BUN Liver f unction tests,
including total protein and albumin
Prealbumin may be used as a nutritional
mar ker Ser um insulinlike
growth factor I (IGF-I)
Insulinlike growth factor binding protein (IGF-BP3)
Human immunodeficiency vir us (HIV) testing
Sweat chloride test
T
hyroid f unction tests Stool studies for parasites or malabsorption
Immunoglobulins
Purified protein
derivative (PPD) skin test
Radiological studies
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TRE ATMENT
OUTP ATIENT INP ATIENT
DIAGNOSTIC THERAPEUTIC
Obser vation of Feeding
Parental-child interaction
Dietary habits
Perform tests & consults
Dehydration
Anemia
Infection
Electrolyte imbalance
Specific therapy
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DIET
Long-term goal for every child with failure to thrive is to provide adequate ener gy intake for growth!!!
Infants may be given concentrated formulas, assumingrenal f unction is normal
In toddlers, supplemental high-ener gy formulas as much as 30 kcal/oz are used.
Supplements for older children may include addingcheese, sour cream, butter, mar garine, or peanut butter to meals.
High-ener gy (approximately 1 kcal/mL) shakes
Multivitamin and mineral supplements, including iron and zinc, usually are recommended to all undernourished children.
In children with or ganic failure to thrive, continuous nighttime tube feeding also may be used to increase their ener gy intake.
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PROTEIN ENERGYPROTEIN ENERGY
MALNUTRITIONMALNUTRITION
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Definition of Malnutrition
The cellular imbalance between the
supply of nutrients and ener gy andthe body's demand for them to
ensure growth, maintenance, and
specific f unctions. (WHO)
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Protein: deficit in amino acids needed for cell str ucture, f unction
Ener gy: calories (or joules) derived from macronutrients: protein, carbohydrate and fat
Micronutrients: vitamin A, B-complex, iron, zinc, calcium, others
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EPIDEMIOLOGY
In 2000, WHO estimated that malnourished children numbered 181.9 million (32%) in developing countries.
Estimated 149.6 million children younger than 5 years are malnourished when measured in terms of weight
for age. South Central Asia and eastern Africa, about half the
children have growth retardation due to protein-ener gy malnutrition.
Approximately 50% of the 10 million deaths each year
in developing countries occur because of malnutrition
in children younger than 5 years. In kwashior kor,
mortality tends to decrease as the age of onset
increases.
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PEM
PRIMARY
ACUTE
ST ARV ATION
CHRONIC
MARASMUS
KWASHIORKOR
MARASMIC-KWASHIORKOR
SECONDARY
GI DisordersWasting
disordersMetabolic demands
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Marasmus
Severely wasted (emaciated) & stunted
³Old Man´face, wrinkled
appearance, sparse hair,
baggy pants appearance.
No edema, fatty liver, skin changes
Too little breast milk or
complementary foods
< 2 yrs of age
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Kwashiorkor
EdemaMental changes
Hair changes
Fatty liver
Flaky paint Dermatosis/ Mosaic skin
Infection
High case fatality
Low prevalence
1 to 3 yrs of life
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Marasmic-Kwashior kor
edema occurring in children
who are other wise marasmic
and who may or may not have
other signs of kwashior kor.
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HISTORY
In children, the findings of poor weight gain or weight loss; slowing of linear growth; and behavioral changes, such as irritability, apathy, decreased social responsiveness, anxiety, and attention deficit may indicate PEM. In particular, the child is apathetic when undisturbed but irritable when picked up.
Kwashior kor characteristically affects children who are being weaned. Signs include diarrhea and psychomotor changes.
Patients with PEM can also present with non-healing
wounds. This may signify a catabolic process that requires nutritional inter vention.
Detailed dietary history, growth measurements, BMI are essential
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PHYSICAL EX AMINATION
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IN
VESTIGATION
S Blood glucose
Examination of blood smears by microscopy or direct detection testing
Hemoglobin Urine examination and culture
Stool examination by microscopy for ova and parasites
Ser um albumin HIV test
Electrolytes
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...significant findings
hypoalbuminemia (10-25 g/L)
hypoproteinemia (transferrin, essential amino acids, lipoprotein)
Hypoglycemia
Plasma cortisol and growth hormone levels are high, but insulin secretion and insulinlike growth factor levels are decreased.
The percentage of body water and extracellular water is increased.
Electrolytes, especially potassium and magnesium, are depleted. Levels of some enzymes (including lactase) are decreased
circulating lipid levels (especially
cholesterol) are low. Ketonuria and a decrease in the
urinary excretion of urea because of decreased protein intake.
In both kwashior kor and marasmus, iron deficiency anemia and metabolic acidosis are present.
Urinary excretion of hydroxyproline is diminished, reflecting impaired growth and
wound healing. Increased urinary 3-methylhistidine is a reflection of muscle breakdown and can be seen in marasmus.
Malnutrition also causes immunosuppression, which may result in false-negative tuberculin skin test results and the subsequent failure to accurately assess for tuberculosis.
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TREATMENT
First step in the treatment of PEM is to correct fluid and electrolyte abnormalities and to treat any infections (hypokalemia, hypocalcemia, hypophosphatemia, and hypomagnesemia).
Second step (which may be delayed 24-48 h in children) is to supply macronutrients by dietary therapy. Milk-based formulas are the treatment of choice. At the beginning of dietary treatment,
patients should be fed ad libitum. After 1 week, intake rates should approach 175 kcal/kg and 4g/kg of protein for children. A daily multivitamin should also be added.
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Treatment of Severe PEM
Nutritious feeds: Breast milk;
Liquid feeds of skimmed milk, oil, sugar; soft
Cereal gr uels with milk, oil, sugar soft
Soft ripe fr uit, cooked vegetables
Establish a daily, graduated intake of - ~3-4 g protein per kg (actual) body wt
~200 kcal of ener gy per kg body wt
V Reddy, Protein Ener gy Malnutrition. Diseases of Children in the Subtropics & Tropics, 4thed Ed P Stanfield et al, London:Hodder & Stoughton, 1991
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Treatment of Severe PEM
(cont¶d)
More frequent small feeds better than lar ge meals
Micronutrient supplements: To treat clinical conditions (eg, anemia,
xerophthalmia)
To prevent f urther deficiencies
Water for thirst
Treat infections and illnesses; eg, Diarrhea: ORS & zinc
Antibiotics, as indicated
Prevent hypothermia36
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PROGNOSIS
Some children develop chronic malabsorption and pancreatic insufficiency. In very young children, mild mental retardation may develop and persist until at
least school age. P
ermanent cognitive impairment may occur, depending on the duration, severity, and age at onset of PEM.
The extent of growth failure and the severity of hypoproteinemia, hypoalbuminemia, and
electrolyte imbalances are predictors of a poorer prognosis.
Underlying HIV infection is associated with a poor prognosis.
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THANK YOU !