failure to thrive with notes

04/11/23 Failure to Thrive Shannon Pittman, M.D.

Failure to ThriveFailure to ThriveFailure to ThriveFailure to Thrive

Shannon Pittman, M.D.Shannon Pittman, M.D.

University of Mississippi University of Mississippi

Jackson, MSJackson, MS

http://www.peacecorpsonline.org/messages/messages/2629/1008996.html

http://bluegoldfish.blogs.com/surface/2004/05/present_from_pr.html

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Objectives• To define failure to thrive (FTT)• To identify major classification of FTT

•To discuss diagnostic workup of FTT •To discuss treatment of FTT

Things We Will Not Cover

• Geriatric FTT– Am Fam Physician. 2004 Jul

15;70(2):248, 257.– Rehabil Nurs. 2005 Jul-Aug;30(4):152-

• Adolescent FTT

Things We Will Not Cover

• Other specific causes (e.g.)– Congenital defects – Celiac disease– HIV/AIDS– Metabolic disorders– CHF (reference for Jenny)

• Prog Pediatr Cardiol. 2000 Sep 1;11(3):195-202.

Why Do We Have to Talk About it at All?

• Personal– Depending on current status in app. 9, 21, or 32

months you will sit for the ABFP (13%-pediatrics)– ACGME competencies / AAFP core recommendations

• Patients– Parental concerns

• Doc, is my baby growing right?– Cognitive development

• Arch Dis Child. 2005 Sep;90(9):925-31. Epub 2005 May 12.

• J Child Psychol Psychiatry. 2004 Mar;45(3):641-54.

Clinical Vignette

• 15 month old admitted with lethargy from dermatology office

• Prior to admit, several days of decreased activity

• Med hx remarkable for eczema, treated with topical steroids

Clinical Vignette• Wgt and ht both below 5th

percentile, but had grown along the 25th percentile until age 4mo

• Extensive erythematous plaques on her back, diaper region, thighs, and polpliteal fossa bilaterally

Clinical Vignette

• What concerns you about this child

• What history questions should you ask

• What labs would you order• How would you manage pt’s care

Okay, Tell Me What Happens Next -

• Afternoon clinic• 10 Patients scheduled

– Everyone of them showed up

• Your 5th pt is new & has a typed list

• It’s 4:00 and you are on pt 6 who happens to be a 9 mo well child

http://www.cha.state.md.us/edcp/html/immpg.html

We’re not alone• In England, 54% of GP failed to

diagnosis FTT• Residency clinic, 41% with delayed

dx• Residency clinic, 29 dx, 100% dx

incorrectly

FTT – Definition

“Inadequate physical growth diagnosed by observation of growth over time using a standard growth chart”

Normal Growth• Average wgt 7 lbs (3kg)

– Double by 4 months, triple by 12• Grow 25 cm in length during 1st

year• Make sure you have the right chart

– Premature– Breastfeeding – www.cdc.gov/growthcharts

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

FTT• HISTORY ! HISTORY! HISTORY!

– Prenatal– Feeding

• # oz needed in 24 hours – Wgt (kgs) x 5 (need 100 kcal/kg/day)

• How formula prepared• Good diet history (3 day journal)

– Bowel habits

FTT• Physical

– Gomez Criteria• <60 = severe; 61-75 = mod; 76-90 = mild

– Kwashiorkor – protein malnourishment– Marasmus – caloric deficiency– Short Stature Syndrome– Constitutional Delay

FTT - Classification• Organic FTT

– Pre/postnatal

• Nonorganic FTT (NOFT)– Pre/postnatal

• Mixed (25%)

FTT - Classification• Organic FTT

– Prenatal Causes• Prematurity w/complications• Toxic exposure

– Postnatal• Inadequate intake

– Lack of appetite– Inability to suck/swallow

FTT - Classification• Organic, postnatal cont.

• Poor absorption and/or use of nutrients– GI disorder (celiac, CF)– Inborn errors of metabolism

• Increased metabolic demand– Hyperthyroidism– Chronic Disease

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

Recap - ClassificationFailure to Thrive

Organic Nonorganic

Prenatal Postnatal

Toxic Exposure Inborn errors

Prenatal Postnatal

Malnourished mother Abuse/Neglect

FTT - Workup• +/- Basic screening labs

– CBC, Chemistry, & UA

• Specific test directed by history– HIV, ESR, TSH, Sweat chloride test,

serum IGF-I, serum IgA/IgG antigliadin antibiodies

• X-rays for bone age

FTT – Treatment• High calorie diet for catch up growth

– 150% of recommended daily caloric intake based on expected wgt

• +/- Feeding behavior modification• Psychosocial involvement/

intervention• Close follow up

– Physical and cognitive delays• Hospitalization when necessary

Clinical Vignette

• 15 month old admitted with lethargy from dermatology office

• Prior to admit, several days of decreased activity

• Med hx remarkable for eczema, treated with topical steroids

Clinical Vignette• Wgt and ht both below 5th

percentile, but had grown along the 25th percentile until age 4mo

• Extensive erythematous plaques on her back, diaper region, thighs, and polpliteal fossa bilaterally

Clinical Vignette• What concerns you about this

child• What history questions should you

ask• What labs would you order• How would you manage pt’s care

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

Take Home

The keys to diagnosing FTT is finding the time to accurately measure and

plot wgt/ht and then access the trend

http://www.cha.state.md.us/edcp/html/immpg.html

Afternoon clinic

10 Patients scheduledEveryone of them showed up

Your 5th pt is new & has a typed list

It’s 4:00 and you are on pt 6 who happens to be a 9 mo well child

Any Questions?

www.child.com/.../ baby_babble.jsp

References• Listernick, R. (2004). Accurate feeding history key to

failure to thrive. Pediatr Ann, 33:3, 161-9.• Burgos, R., Jutte, D. (2000). Resident’s 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 gastroenterologist’s

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.

Thanks for Your Attention!

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