When Simple and Natural Gets Complicated Failure to Thrive.

When Simple and Natural Gets Complicated

Failure to Thrive

“I’m a Failure to Mother”

• Be careful of pejorative language – Parental Deprivation Syndrome (1960)

• Primary need is to instill confidence in the family

“I’m a Failure to Mother”

“Growth Deficiency”

• Weight based assessment

• Insufficient growth velocity

Weight

Height

Head Circumference

• Organic/Inorganic

Start at the Beginning

Uteroplacental Insufficiency

Maternal Hypertension

Diabetes Mellitus

Renal Disease

Collagen Vascular Disease

Genetics

Parental - Age

Fetal – Trisomy, Russell-Silver Syndrome

Maternal Nutrition - time dependant, relatively resistant


40% of Growth Deficient infants

are born with birth weights of less than 2500 grams (5 pounds 8 ounces)


During fetal period, endocrine system has little impact on growth.

Pituitary aplasia, congenital hypopituitarism or growth hormone insensitivity will have NORMAL weight at birth

Normal Growth Variation

More than half of newborns experience an upward shift of growth during the first 3 months

30% of normal babies experience a downward shift between the ages of 3 and 18 months

Children reach genetic length by 2 years

Many children have significant weight decrease around between 9 and 15 months

Timing of Abnormality

Severe Anatomic Abnormality

Infection – GBS, TORCH

Breast Feeding Dysfunction

Cardiac Anomaly

Cystic Fibrosis

Milder Anatomic Abnormality

Severe Reflux

Protein Sensitivity

Deprivation

Chronic Reflux

Inappropriate Diet

Heavy Metal Poisoning

Birth 1 week 2-4 weeks 1 month 6 months 9 months 1 year

Causes of Failure to Thrive

Inadequate Input

Excessive Output

Increased Utilization

Humans are a Closed Energy System

textCALORIES IN

-METABOLIC USE

-CALORIES LOST/

NOT USED=

ZERO


Inadequate Input

Excessive Output


Inadequate Input

1. INSUFFICIENT NUTRITION OFFERED

2. MATERNAL/CHILD AXIS DYSFUNCTION

3. PSYCHOSOCIAL DYSFUNCTION4. SEVERE GASTROESOPHAGEAL

REFLUX / VOMITING5. MECHANICAL PROBLEMS6. SUCKING OR SWALLOW

DYSFUNCTION

Inadequate Input

INSUFFICIENT NUTRITION OFFEREDMaternal Medical StressAnti-histaminesNarcotics/AlcoholInappropriate or incorrectly

constituted formulaDisplacement of nutritious offering

by poor nutritional component

Vitamin deficiencyLead (5-35 mcg/dL) potentiated by

poor Calcium and Vitamin D

Inadequate Input

MATERNAL/CHILD AXIS DYSFUNCTION

Inappropriate knowledge of infant/child diet

Sub-optimal feeding techniqueMaternal depressionPoor bonding (NICU, illness, maternal

aversion, abuse)

Inadequate Input

PSYCHOSOCIAL DYSFUNCTION25% of children in Tennessee live

below the poverty levelIn Chattanooga 80% of African-

American children are born to single mothers (poor social network)

Inadequate Input

PSYCHOSOCIAL DYSFUNCTIONMarital stressDomestic violenceParental employmentChildren of mother’s under 18

have poorer growth and twice as likely to be abused

Number and age of siblings/health of others in the family

Homelessness or home instability/unstable transportation

Inadequate Input

SEVERE GASTROESOPHAGEAL REFLUXPoor intake Pain feedback loop

VOMITINGInfectious gastroenteritis/post-vial ileusChronic pyelonephritisIncreased intracranial pressureCyclic vomitingPoorly controlled Abdominal migrainesAdrenal insufficiencyIpecac

Inadequate Input

MECHANICAL PROBLEMSCleft paletteMicognathia or MacroglosiaTight labial frenulumNasal obstructionIntestinal Obstruction

(Volvulus, Intusception, Hirschsprung’s,

Pyloric Stenosis)Chronic constipationAdenoidal hypertrophyDental lesions

Inadequate Input

SUCKING OR SWALLOW DYSFUNCTIONNeonatal Abstinence SyndromeCNS pathology (stroke, tumor,

hydrocephalus)Genetics Syndromes (Trisomy)Cardiopulmonary DiseaseNeuromuscular weakness/toneCerebral PalsyAnorexia of chromic infection, immune

deficiency, leadBehavioral (apathy or rumination)


Inadequate Input

Excessive Output



CARDIAC DISEASE Congenital or Acquired

SEPSIS CHRONIC RESPIRATORY INSUFFICIENCY

Bronchopulmonary dysplasiaCystic fibrosis

RENAL DISEASEpartial posterior valves, severe reflux

with UTI, Renal Tubular AcidosisHYPERTHYROIDISM


CHRONIC/RECURRENT SYSTEMIC INFECTION

UTI, Tuberculosis, TORCHHIV – degree of viremia

correlates with poor growth

MALIGNANCYINFLAMMATORY BOWEL DISEASEDIABETES MELLITUSCHRONIC SYSTEMIC DISEASE

Juvenile Idiopathic Arthritis


Metabolic DiseaseInborn errors of metabolism

(normal infant that deteriorates with lethargy, poor feeding, convulsions, vomiting)

Storage diseasesHypercalcemiaAdrenal insufficiency


Inadequate Input

Excessive Output


Excessive Output

Biliary AtresiaNecrotizing Enterocolitis or Short Bowel SyndromeMalabsorption

Lactose intolerance Cystic fibrosisCardiac disease Inflammatory bowel diseaseMilk/food allergy or irritation ParasitesCystic Fibrosis Celiac Disease

Infectious diarrheaRenal losses

Fanconi Syndrome Chronic renal insufficiencyVitamin D resistance Type I Diabetes Mellitus


Inadequate Input

Excessive Output


Isolated Linear Growth Deficiency

Familial Intrinsic Short StatureChromosomal Abnormality

Trisomy 13, 18, 21

Chromosome 22 del

Gonadal Dysgenesis

(45, X)Skeletal Dysplasia

Endocrine DysfunctionPituitary

InsufficiencyHypothyroidismGH

deficiency/resistance Younger children

Hypophosphatemic

Rickets Older children

HypercortisolismPseudohypo-

parathyroidism

Isolated Linear Growth Deficiency

Management Tips

•If clinically and socially stable, give yourself time and use frequent observational follow up•Even if clear organic cause evident do not forget about psychosocial components – most organic causes have mixed non-organic component•Be clear with family about seriousness of child’s status

–insist they be seen–“Ring the Bell” - get all hands on deck

Management Tips

•Look the grandmothers in the eye, get them on your side, ask them what they think is wrong and give them jobs•Ask all important members of the team for their assessment and theories on treatment•Normalize familial expectations•Access parental dietary attitudes

–Unhealthy, sweet, hot/cold foods, fattening, food allergy

Management Tips

•Ask every time you meet with the family–Diet

•“What are you feeding the child?”–Caloric Intake

•“What exactly did your child eat in the last 24 hours?”

–Eating Environment•“How are you feeding the child?”

–“What do you Think about your child’s feeding”

Expected Daily Weight Gaingrams/day

0 to 3 months 303 to 6 months 186 to 9 months 129 to 12 months 91 to 3 years 8

“Catch Up” weight gain is two to three times greater than average for age

Calculating Calorie Need

Dietary Reference Intake (kcals/kg/day)0 to 6 months 1086 to 12 months 981 to 3 years 102

“Catch Up” calorie calculation 150% DRIAlternative method(DRI x median weight for length)/actual weight

Basal Intake Rate for Protein

2.2 grams/kg per day

Other Considerations

• Calculated calorie requirements are estimates. Severe failure to thrive may require greater than 200kcal/kg• Target calorie intake should be achieved over 5-7 days• Malnutrition is usually associated with some degree of anorexia• High calorie feedings are hyperosmolar and may lead to diarrhea or malabsorption• Rapid refeeding may lead to hyperkalemia or

hypophosphatemia

Vitamin and Mineral Supplementation

•ZINC–No reliable lab assessment–Baseline addition

•IRON–If Hemoglobin, Hematocrit or MCV labs indicate further work up add to diet

Feeding Strategy

• Start with small quantities and advancing as tolerated• Pushing feeding further apart• Assisted feeding to help caregiver

recognizing and responding to cues of hunger and satiety, identify

active feeding• Monitoring latch quality and persistence of latch

Increasing Milk Caloric Content - INFANTS

•Breast Milk–22 kcal/oz: add ½ scoop of formula to 4 ½ ounces–24 kcal/oz: add 1 scoop of formula to 5 ounces

•Formula–22 kcal/oz: add 2 ½ scoops of formula to 4 ½ ounces of water–24 kcal/oz: add 3 scoops of formula to 5 ounces of water

Increasing Milk Caloric Content - CHILDREN

•Increase calorie content of foods child likes to eat–Adding rice cereal to pureed foods–Replacing milk with high calorie substitutes–Limiting low nutrition liquids–Adding cheese, butter, sour cream, peanut butter to fruits and vegetables–Total energy and protein is more important than variety

Increasing Milk Caloric Content - CHILDREN

Increasing Caloric Density of Foods for Toddlers

Other Recipes

• 8 ounces of whole milk plus 2 Tbsp nonfat dry milk powder = 24 calories/ounce• 8 ounces of whole milk plus 3 Tbsp nonfat dry milk powder = 28 calories/ounce• 1 cup of whole milk, 1 package of instant breakfast and 1 cup ice cream = 430 calories

Adequate Response

• With adequate caloric and protein intake, “Catch Up” growth is initiated in 2 to 14 days• 4-9 months of accelerated growth must be maintained to restore a child’s weight to height• “Catch Up” height may lag behind weight by several months

Medical Appetite Stimulation

Cyprohepatidine has no proven long-term benefit

Lemons PK, Dodge NN. Persistent failure-to-thrive: a case study. J Pediatr Health Care 1998; 12: 27.

Indications for Hospitalization

•Severe malnutrition•Significant dehydration•Serious medical problems•Psychosocial risk to child•Failure to respond to outpatient

management•Precise documentation of caloric intake•Extreme parental impairment or anxiety•Severely disrupted parent-child axis•Family issues make outpatient therapy impractical

Supplement Oral Feedings

•Severe malnutrition that is not achieving adequate catch up in 4 to 6 weeks consider nasogastric feedings•Discontinue when consistent weight gain has been shown for 4 to 6 months•If weight gain remains inadequate after 3 to 4 months of nasogastric feeds gastrostomy tube may be appropriate

Frequent Follow Up

•Weekly follow up should continue until solid baseline growth is demonstrated

•Use ancilary team members for observation–Home health nurse–WIC–Dietitian

Refeeding Syndrome

•Sweatiness•Hyperthermia•Hepatomegaly – increased glycogen deposition•Widening of the cranial sutures- brain

growth faster than the skull•Increased periods of sleep•Fidgetiness or hyperactivity

Refeeding Syndrome

•Follow Potassium and Phosphorus in the acute period of reinstating nutrition•Initial intracellular ion shifts my cause

–Hypokalemia–Hypophosphotemia

•Can produce serious arrhythmias and muscle weakness

Can laboratory studies help diagnosis and management?

Can laboratory studies help diagnosis and management?

Not UsuallySills et al (1978) 2607 laboratory tests were undertaken for the entire study group of 185 children hospitalized for failure to thrive.

Only 36 (1.4%) of tests were of positive diagnostic significance. All of them were in the 34 patients whose diagnosis was strongly suggested by history and examination.

Homer et al (1981)82 children hospitalized for failure to thrive. History and examination was most sensitive indicator of organic disease.

Berwick et al (1982)122 infants hospitalized for failure to thrive.

Only 0.8% of tests were of positive diagnostic significance and 3.8% contributed to management. GI related labs were most helpful but indication for labs usually appearant in history and examination.

How can laboratory studies help?

•Infection or chronic inflammation •Electrolyte irregularity and monitor for refeeding impact•Iron deficiency•Vitamin deficiency(B12 or folate)•Nutritional status (albumin and prealbumin)•Fat soluble vitamins (ADEK)•Evaluate signs of specific disease

–Cystic Fibrosis–Metabolic Disease


ELECTROLYTE IRREGULARITY AND MONITOR REFEEDING IMPACT

Hypernatremic hypovolemiaPoor fluid volume from feeding

HyponatremicUnmanageble free water volumeRTAHyperaldosteronism

HypomagnesiumStool loses

Hypokalemia/Hypophosphatemia


IRON DEFICIENCYMost common nutritional deficiency in

childrenLabs Mean Corpuscular Volume

Serum Iron Plasma Ferritin

sensitive but also an acute phase reactant

Total Iron Binding Capacity, Transferrin

Ususally associated with hypochromic, microcytic morphology


WATER SOLUBLE VITAMIN DEFICIENCY

Macrocytic AnemiaSerum B12 and Folate levels can be

directly measured

FAT SOLUBLE VITAMIN DEFICIENCYVitamin A, E and 25-hydroxyvitamin D can

be measuredProthrombin Time is a good proxy measure

of Vitamin K


EVALUATING NUTRITIONAL STATUS Prealbumin

Synthesized in liverHalf-life 2 daysExquisitely sensitive to adequate

levels of protein and energy intake

Low levels in children <13, neonates <4

AlbuminSynthesized in liverHalf-life 14-20 days so reflect last

three weeks of nutritionBe careful with large protein losses

from circulationAscites, Renal disease, GI

losses


Cystic FibrosisStool for fecal fat or trypsinogen

Other causes of malabsorptionStool for reducing substances (carbohydrate

enzyme deficiencies)

Celiac DiseaseAntibody Screening (Celiac Panel)

Endocrine DysfunctionGrowth hormone, IGF1, IGFBP3, TSH, free T4Rule out if height above 50th percentile


ZINCSerum Zinc level have a high degree of

variation through the dayAssume Zinc deficiency in malnutrition/growth failure

Long Term Considerations

Systematic review of cohort studies shows

Decreased IQ of questionable clinical significance

Height and weight seem to be lower percentiles

Psychomotor and educational outcomes seem to be

lower than population norms

• Child with no serious congenital anomaly or confirmed genetic disorder

• Greater than 5 organ symptoms involvement• Multiple presentations to previous institutions

for evaluation• Long and convoluted history with multiple

identifying features as treatment adherence failure leads to next subspecialty evaluation

• Refusing feeding team evaluation, home evaluation or changing/adding formula/supplement without medical consult

• History of maternal pregnancy complications

• Three of more parental-reported allergies

Red Flags for Medical Child Abuse in Growth Deficiency

References

•Berwick DM et al. Failure to Thrive: Diagnostic Yield of Hospitalization. Archives of Disease in Childhood. 1982; 57: 347-351.•Bithoney WG, Dubowitz H, Egan H. Failure to thrive/growth deficiency. Pediatric Rev 1192; 13: 453.•Ellerstein NS, Ostrov BE. Growth patterns in children hospitalized because of caloric-deprivation failure to thrive. Am J Dis Child 1985; 139: 164.•Frank DA. Failure to thrive. In: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 3rd ed, Augustyn M, Zuckerman B, Caronna EB (Eds), Lippincott Williams & Wilkins, Philadelphia 2011. p.204.•Frank D, Silva M, Needlman R. Failure to thrive: Mystery, myth and method. Contemp Pediatr 1993; 10: 114.•Frank DA, Zeisel SH. Failure to thrive. Pediatr Clin North Am 1988; 35: 1187.•National Research Council, Food and Nutrition Board. Recommended Daily Allowances. National Academy of Sciences, 10th ed, National Academy Press, Washington, DC 1989.•Goldbloom RB. Growth failure in infancy. Pediatr Rev 1987; 9: 57.•Grey V, Landis L, Pall H, Drury D. Monitoring of 25-OH vitamin D levels in children with Cystic Fibrosis. J Pediatr Gastroenterol Nutr 2000; 30: 314.•Haynes CF, Cutler C, Gray J, Kempe RS. Hospitalized cases of nonorganic failure to thrive: the scope of the problem and the short-term lay health visitor intervention. Child Abuse Negl 1984; 8: 229.

References

•Homer C. et al. Categorization of Etiology of Failure to Thrive. American Journal of the Diseases of Children. Sept 1981; 135: 848-851.•Ingenbleek Y, Young V. Transthyretin (prealbumin) in health and disease: nutritional implications. Annu Rev Nutr 1994; 14: 495.•Jafee AC. Failure to Thrive: Current Clinical Concepts. Pediatrics in Review 2011; 32: 100.•Lemons PK, Dodge NN. Persistent failure-to-thrive: a case study. J Pediatr Health Care 1998; 12: 27.•Mash C, Frazier T, Nowacki S, Worley S, Goldfarb J. Development of Risk-Stratification Tool for Medical Child Abuse in failure to Thrive. Pediatrics 2011; 128; e1467.•Maggiono A, Lifshitz F. Nutritional management of failure to thrive. Pediatr Clin North Am 1995; 42: 791.•MacLean WC Jr, Lopez de Romana G, Massa E, Graham GC. Nutritional management of chronic diarrhea and malnutrition: primary reliance on oral feeding. J Pediatr 1980; 97:316.•Measurement of visceral protien status in assessing protein and energy malnutrition: standard of care. Prealbumin in Nutritional Care Consensus Group. Nutritional Care Consensus Group. Nutrition 1995; 11:169.•Rudolf M, Logan S. What is the long term outcome for children who fail to thrive? A systematic review. Arch Dis Child 2005; 90: 925-931.•Schmitt BD, Mauro RD. Nonorganic failure to thrive: an outpatient approach. Child Abuse Negl 1989; 13: 235.

References

•Seres DS. Surrogate nutritional markers, malnutrition and adequacy of nutrition suppot. Nutr Clin Pract 2005; 20: 308.•Sills RH. Failure to Thrive. The Role of Clinical and Laboratory Evaluation. American Journal of Diseases of Children. Oct 1978; 132: 967-969.•Smith DW, Truog W, Rogers JE, et al. Shifting linear growth during infancy: illustration of genetic factors in growth from fetal life through infancy. J Pediatr. 1976;89:225-230•Swartz I. Failure to Thrive: An Old Nemesis in the New Millenium. Pediatrics in Review 2000; 21: 257.•Tougas L, et al. Dietary Manual, Department of Nutrition. Boston, MA: Children’s Hospital; 1991•Walravens PA, Hambridge KM, Koepfer DM. Zinc supplementation in infants with a nutritional pattern of failure to thrive: a double-blind, controlled study. Pediatrics 1989; 83: 532.•Wright CM. Identification and management of failure to thrive: a community perspective. Arch Dis Child 2000; 82: 5.•Zenel JA Jr. Failure to thrive: a general pediatrician’s perspective. Pediatr Rev 1997; 18: 371.

When Simple and Natural Gets Complicated Failure to Thrive.

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