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Failure to Thrive
In the State of Georgia, an adult is required to pass both a written and a road test to get a drivers license. No such requirement exists for parenting.
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Failure to Thrive
Objectives
To define failure to thrive (FTT) To identify major classification of FTT
To discuss diagnostic workup of FTT To discuss treatment of FTT
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Failure to Thrive
Failure to Thrive
A descriptive term, not a specific diagnosis Diagnoses when a childs weight for age is below the fifth percentile or crosses two major percentile lines The key is to accurately measure wt, ht at each visit.
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Failure to Thrive
A sign the describes a particular problem Requires us to STOP and THINK.
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Failure to Thrive
Failure to Thrive
Best defined as inadequate physical growth Diagnosed by observation of growth over time using standard growth charts. Preferred growth charts are from the National Center for Health Statistics (NCHS) found at www.cdc.gov
,
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FTT Criteria
Ht/Wgt less than 3rd to 5th percentile for age on >1 occasion Ht or Wgt falling 2 major percentiles Below 10th percentile for ht/wgt < 80% of ideal body wgt for age Head circumference important, but not part of FTT entity
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OK135S053
OK135S054
OK135S055
OK135S056
Selective Differential Dx
Inadequate caloric intake Inadequate absorption Increased metabolism Defective utilization
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FTT Definition
Inadequate physical growth diagnosed by observation of growth over time using a standard growth chart DO HT, WT and observe trends
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FTT
HISTORY ! HISTORY! HISTORY!
Prenatal Feeding
# oz needed in 24 hours
Wgt (kgs) x 5 (need 100 kcal/kg/day, formula 20kcal/oz)
Bowel habits
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Normal Growth
Average wgt 7 lbs (3kg)
Grow 25 cm in length during 1st year Make sure you have the right chart
Premature Breastfeeding Ethnic Down Syndrome www.cdc.gov/growthcharts
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Normal Growth
Newborns can lose 10% of weight in first few days, gain back by 2 weeks Infants gain 1 kg/month 0-3 months gain .5 kg/month 3-6 months gain .33kg/month 6-9 months
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Bassali et al, Failure to Thrive www.emedicine,com/PED/topic7 38.htm, updated April 25, 2006
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Normal Growth
AGE Median Daily Weight Gain Grams 26-31 grams 17-18 grams 12-13 grams 9 grams 7-9 grams 6 grams
Bassali et al, Failure to Thrive www.emedicine,com/PED/topic7 38.htm, updated April 25, 2006
0-3 months 3-6 months 6-9 months 9-12 months 1-3 years 4-6 years
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Prematurity
Maternal malnutrition
Toxic exposure in utero Alcohol, smoking, meds Infections IUGR Abnormal chromosomes
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Bassali et al, Failure to Thrive www.emedicine,com/PED/topic7 38.htm, updated April 25, 2006
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Inadequate absorption
Celiac disease Cystic fibrosis Cows milk allergy Poverty and food shortage Vitamin or mineral deficiency Biliary atresia or liver disease Necrotizing enterocolitis or short gut
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Increased metabolism
Hyperthyroidism Chronic infection- HIV, other immune diseases Hypoxemia-congenital heart defects and chronic lung disease
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Defective utilization
Genetic abnormalities- trisomies 21, 18, 13 Congenital infections Metabolic disorders- storage diseases, amino acid disorders
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Introduction to IEM
Usually a single gene defect that causes a block in metabolic pathways. Problems are because of accumulation of enzyme substrate behind the metabolic block or deficiency of the reaction product.
IEM
In some instances the substrate is diffusible & affects distant organs & in some there is just a local effect ( lysosomal storage disease ).
Odors :
IEM Associations
Glutaric acidemia type 2 sweaty feet Isovaleric acidemia sweaty feet Hawkinsuria swimming pool MSUD maple syrup Methionine malabsorption cabbage Multiple carboxylase deficiency tomcat urine Oasthouse urine disease hops like PKU mousy or musty Trimethlyaminuria rotting fish Tyrosinemia rancid fishy or cabbage like
FTT
Physical
Gomez Criteria- comparing the current expected weight for age 50 percentile
<60% = severe; 61-75% = mod; 76-90% = mild
Kwashiorkor protein malnourishment Marasmus caloric deficiency Short Stature Syndrome Constitutional Delay
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FTT - Classification
Organic FTT
Pre/postnatal
Mixed (25%)
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FTT - Classification
Nonorganic
Prenatal
Malnourished mother ? Lack of prenatal bonding
Postnatal
Poor feeding skills/disorder Dysfunctional family Difficult parent-child interactions Difficult Child Abuse/Neglect
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FTT - Classification
Organic, postnatal cont.
Poor absorption and/or use of nutrients
GI disorder (celiac, CF) Inborn errors of metabolism
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FTT - Classification
Organic FTT
Prenatal Causes
Prematurity w/complications Toxic exposure
Postnatal
Inadequate intake
Lack of appetite Inability to suck/swallow
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Recap - Classification
Failure to Thrive
Organic
Nonorganic
Prenatal
Postnatal
Prenatal
Postnatal
Toxic Exposure
Inborn errors
Malnourished mother
Abuse/Neglect
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FTT - Workup
+/- Basic screening labs
CBC, Chemistry, & UA
FTT Treatment
High calorie diet for catch up growth
150% of recommended daily caloric intake based on expected wgt
Summary: G.R.O.W.T.H.
Gather history and extensive physical Remember genetic contribution Only order basic labs in initial eval Wonder about zebras Track growth trends Hospitalize or hormonally treat
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Patients
Cognitive development
Doc, is my baby growing right? Arch Dis Child. 2005 Sep;90(9):925-31. Epub 2005 May 12. J Child Psychol Psychiatry. 2004 Mar;45(3):641-54.
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Take Home
The keys to diagnosing FTT is finding the time to accurately measure and plot wgt/ht and then access the trend
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References
Listernick, R. (2004). Accurate feeding history key to failure to thrive. Pediatr Ann, 33:3, 161-9. Burgos, R., Jutte, D. (2000). Residents column: doctor, is my child growing ok?. Pediatr Ann, 29:9, 585-7. Krugman, S., Dubowitz,H. (2003). Failure to thrive. American Fam Phy, 68:5, 879-84. Schwartz, R., Abegglen, J. (1996). Failure to thrive: an ambulatory approach. Nurse Pract, 21:5, 19-31. Careaga, M., Kernder, J. (200). A gastroenterologists approach to failure to thrive. Pediatr Ann. 29:9, 558-67. Bassali, R., Benjamin, J. (2004, August 11). Failure to Thrive. eMedicine. Retrieved September 17, 2005, from http:///www.emedicine.com/ped/topic738.htm.
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