FTT &Types of Nutritional Support

BY: Heba A. Al-Omoush 5th year

Overview :

definition of FTT. Types of FTT. Types of nutritional support. enteral VS parenetal. complications of nutritional support.

Failure to Thrive

is defined as the inability to maintain the expected rate of growth over time.

  Growth is assessed by plotting the patient's growth parameters over subsequent visits and comparing the growth rate to normal population growth rates for age.  One set of measurements can not assess rate of growth and therefore is not sufficient to diagnose failure to thrive.

Failure to Thrive (FTT):› Weight below the 5th percentile for age and sex› Weight for age curve falls across two major

percentile lines

Failure to thrive can be subcategorized into three types based on the growth patterns of weight, height, and head circumference.  Dividing failure to thrive into these three types is very helpful because the differential diagnosis is vastly different between the three types.

Type I Failure to Thrive

Type I failure to thrive is characterized by the following growth pattern:

weight:  growth rate significantly reduced or even weight loss

height:  normal rate of growth or only minimally reduced

head circumference:  normal rate of growth

The growth chart below depicts the pattern typically seen in type I failure to thrive.

The majority of patients with failure to thrive have type I failure to thrive in which there is an imbalance between the availability of calories and the caloric requirements of the patient.  This can occur for three reasons:

1.inadequate intake of calories 2.excess losses of calories (vomiting or

diarrhea/malabsorption) 3.increased caloric requirements (for example,

with hyperthyroidism or diencephalic tumor).

Inadequate caloric intake and/or excessive losses (usually secondary to GE reflux) are by far the most common causes of type I failure to thrive (and failure to thrive in general).

Patients with type I failure to thrive are referred to as being "wasted", meaning that they are underweight for their height (evidenced by a low weight:length ratio or low BMI).  This is in contrast to patients with type II failure to thrive who are characteristically "stunted"

Type II Failure to Thrive

Type II failure to thrive is characterized by the following growth pattern

weight:  growth rate significantly reduced or even weight loss

height:  growth rate significantly reduced (in proportion to weight)

head circumference:  normal rate of growth

The growth chart below depicts the pattern typically seen in type II failure to thrive

When you see a patient with this growth pattern, you should think about an endocrine etiology, as these patients actually have short stature.  The most common causes are:

familial short stature constitutional growth delay hypothyroidism, growth hormone deficiency,

hypopituitarism

Patients with constitutional growth delay or familial short stature typically resume a normal growth velocity after crossing the 3rd percentile.  This results in growth curves that are parallel to the 3rd percentile.  Patients with hypothyroidism, growth hormone deficiency, or hypopituitarism typically continue to grow at a suboptimal rate, with growth curves that continue to fall further below the 3rd percentile.

Patients with type II failure to thrive are referred to as being "stunted" meaning that their height for age is decreased, often in proportion to weight.  Therefore, these patients have a normal weight:length ratio or BMI. 

Because this type of failure to thrive is usually not a

result of insufficient caloric intake, nutritional rehabilitation is typically not benefical.  The exception to this is when stunting is secondary to chronic malnutrition.  Chronic malnutrition can result in stunting, but this usually only occurs after months of malnutrition.  In these patients, the decrease in weight velocity precedes the decrease in height velocity (they begin with wasting and progress to stunting).  Provision of adequate calories can result in increased weight velocity followed by increased height velocity with catch-up growth

Type III Failure to Thrive

Type III failure to thrive is characterized by the following growth pattern:

weight:  growth rate significantly reduced or even weight loss

height:  growth rate significantly reduced (in proportion to weight)

head circumference:  growth rate significantly reduced.

The growth chart below depicts the pattern typically seen in type III failure to thrive.

This growth pattern often begins at birth (symmetric IUGR) and usually results from:

1. intrauterine infections2. chromosomal abnormalities 3. prenatal exposure to toxins 

These patients often appear dysmorphic or have CNS

abnormalities.

These patients, like those with type II failure to thrive, are typically stunted with a normal weight:length ratio or BMI.  Because this type of failure to thrive is usually not a result of insufficient caloric intake, nutritional rehabilitation is not beneficial unless wasting is present.

Types of Nutritional Support

When managing patients who are malnourished, or who are at risk to become malnourished, nutritional therapy must be initiated and monitored closely over time.  The goal of therapy is to provide the calories, protein, vitamins, and minerals that are necessary to restore or maintain normal nutritional status.

Developing a nutritional rehabilitation plan is a complex process.   Some key factors to keep in mind when developing a nutritional rehabilitation plan are discussed next.

Enteral vs. Parenteral Nutrition

Once you have decided to provide nutritional support, you must decide the route in which you will provide this support.  Although the decision of enteral vs. parenteral nutrition may seem difficult, it is actually quite simple.  Parenteral nutrition should be used when, and only when, enteral support is not possible or not adequate to meet the nutritional needs of the patient.

Enteral feeding is generally preferred to parenteral nutrition because it is:

1. more physiologic (provides stimulation of the gut)2. more economical3. safer (decreased risk of electrolyte disturbances,

infection, and liver dysfunction)

Occasionally a combination of enteral and parenteral support is necessary to meet the nutritional needs of the patient. 

In this situation, the maximal amount of enteral support possible should be used, with the remainder of nutritional support provided parenterally.

The main symptoms of feeding intolerance which limit the ability to feed enterally are:

vomiting diarrhea abdominal distension or discomfort

Type of Enteral Support When providing enteral support, one should use the most

physiologic method tolerable to the patient.  The feeding regimen should resemble a normal eating pattern as much as possible.

Methods of enteral support from most physiologic to least physiologic are listed below:

1. increased-calorie foods or increased caloric density of infant formula

2. supplementing the diet with oral nutritional drinks like Pediasure or Boost

3. gastric bolus feedings 4. gastric continuous feedings5. jejunal continuous feedings

Gastric continuous feedings should be used when the volumes required for bolus feedings are not tolerated by the patient.

Jejunal feedings are reserved for patients with severely delayed gastric emptying, severe GER, and patients at risk for aspiration.  Jejunal feedings must be given as a continuous drip, as the reservoir function of the stomach is bypassed.

The method of supplying enteral support should be reassessed on a regular basis.  The goal in patients who are receiving gastric or jejunal feeds is to transition back to a more physiologic method of feeding.  Patients who have a feeding tube in place often receive a portion of their nutrition orally and a portion of their nutrition through the tube.  Typically the patient is allowed to feed orally first, and the remainder of the volume goal is given via the tube.  This may be referred to as "nipple-gavage" feeding.  Over time, the goal is to transition the patient completely back to oral feedings if possible.

NG or NJ tubes should be used when the course of therapy is not expected to exceed 1-3 months.  Surgical placement of feeding tubes should be strongly considered in patients who are expected to require long term tube feeding.

Complications of Nutritional Support

As previously mentioned, the refeeding syndrome is a serious complication of nutritional rehabilitation.  Slow progression to the caloric goal and careful monitoring for and treatment of electrolyte abnormalities can prevent life-threatening events.  This complication can be seen with either enteral or parenteral therapy; however, some complications are unique to either enteral or parenteral therapy

Enteral Nutrition1. tubemalposition. 

For example, an NG tube may be misplaced and go into the airway.  This can result in the infusion of formula into the lungs, which of course can be disastrous.  Another example of tube malpositioning is an NG tube that traverses the pylorus and delivers bolus feedings to the small intestine.  This can result in dumping syndrome and/or abdominal discomfort.  Confirmation of tube position should be done prior to using any newly placed feeding tube or if clinical symptoms suggest tube malposition.  This can be done by auscultation, pH testing for gastric acid, or radiographically.

2. irritation of the tube site (can be seen with nasal tubes or surgically placed tubes)

3. infection of the tube site (most often seen with surgically placed tubes).

Parenteral Nutrition

Parenteral nutrition has a variety of complications associated with it.  The three main categories are:

1. infectious:  catheter-related sepsis is a significant risk with parenteral nutrition and can be life-threatening

2. metabolic:  electrolyte abnormalities, hypo- or hyperglycemia, cholestasis

3. mechanical:  complications with line insertion, occluded or misplaced lines

Reference:

http://edactic.medlib.iupui.edu/QMachine.ASP?UID=1O10WXGB&PageId=8&Sess=726824286

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