failure to thrive with notes

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

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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


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


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


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http://www.babybabyphoto.com/family/pages/02baby_flowers.htm


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http://www.kindersigns.com/images/corbis-black-baby.jpg


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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


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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-

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• Adolescent FTT


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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.


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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.


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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


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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


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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


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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


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


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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


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FTT – Definition

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


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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


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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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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


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FTT• Physical

– Gomez Criteria• <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

• Nonorganic FTT (NOFT)– Pre/postnatal

• Mixed (25%)


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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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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


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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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Recap - ClassificationFailure to Thrive

Organic Nonorganic

Prenatal Postnatal

Toxic Exposure Inborn errors

Prenatal Postnatal

Malnourished mother Abuse/Neglect


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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


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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


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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


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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


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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


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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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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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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


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Any Questions?

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


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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). 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.


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Thanks for Your Attention!

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failure to thrive with notes

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