6/11/2014 Failure to Thrive Acknowledge Shannon Pittmann 6/11/2014 Failure to Thrive 2 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. Objectives To define failure to thrive (FTT) To identify major classification of FTT 6/11/2014 Failure to Thrive 3 To discuss diagnostic workup of FTT To discuss treatment of FTT
Failure to Thrive A descriptive term, not a specific diagnosis
6/11/2014 Failure to Thrive 4 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.
Failure to Thrive A sign the describes a particular problem
Requires us to STOP and THINK.
6/11/2014 Failure to Thrive 5
Failure to Thrive Best defined as inadequate physical growth
,
6/11/2014 Failure to Thrive 6 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
FTT Criteria Ht/Wgt less than 3 rd to 5 th
percentile for age on >1 occasion Ht or Wgt falling 2 major percentiles Below 10 th percentile for ht/wgt < 80% of ideal body wgt for age Head circumference important, but not part of FTT entity 6/11/2014 Failure to Thrive 7 OK135S053 OK135S054 OK135S055 OK135S056 Selective Differential Dx Inadequate caloric intake Inadequate absorption Increased metabolism Defective utilization
6/11/2014 Failure to Thrive, Am Fam Physician 2003;68:879-84 12 6/11/2014 Failure to Thrive 13 FTT Definition Inadequate physical growth diagnosed by observation of growth over time using a standard growth chart
DO HT, WT and observe trends 6/11/2014 Failure to Thrive 14 Were not alone In England, 54% of GPs failed to diagnosis FTT Residency clinic, 41% with delayed Dx Residency clinic, 29 Dx, 100% Dx incorrectly
6/11/2014 1. Batchelor JA. Has recognition of failure to thrive changed? Child Care Health Dev 1996;22:235-40 2.Krugman et al. Missed opportunities to diagnose failure to thrive in a family medicine resident practice. Pediatr Res 2000:47 6/11/2014 Failure to Thrive 16 FTT HISTORY ! HISTORY! HISTORY! Prenatal Feeding # oz needed in 24 hours Wgt (kgs) x 5 (need 100 kcal/kg/day, formula 20kcal/oz) How formula prepared Good diet history (3 day journal) Bowel habits 6/11/2014 Failure to Thrive 17 Normal Growth Average wgt 7 lbs (3kg) Double by 4 months, triple by 12 Grow 25 cm in length during 1 st year Make sure you have the right chart Premature Breastfeeding Ethnic Down Syndrome www.cdc.gov/growthcharts
6/11/2014 Failure to Thrive 18 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
6/11/2014 Bassali et al, Failure to Thrive www.emedicine,com/PED/topic7 38.htm, updated April 25, 2006 19 Normal Growth
6/11/2014 Bassali et al, Failure to Thrive www.emedicine,com/PED/topic7 38.htm, updated April 25, 2006 20 AGE Median Daily Weight Gain Grams 0-3 months 26-31 grams 3-6 months 17-18 grams
6-9 months 12-13 grams 9-12 months 9 grams 1-3 years 7-9 grams 4-6 years 6 grams Organic causes of FTT
6/11/2014 Bassali et al, Failure to Thrive www.emedicine,com/PED/topic7 38.htm, updated April 25, 2006 21 Prenatal Causes Post natal causes Prematurity Inadequate intake Maternal malnutrition Poor absorption & or use
Toxic exposure in utero Increased metabolic demand Alcohol, smoking, meds Inadequate absorption Infections IUGR Abnormal chromosomes Incorrect prep of formula Unsuitable feeding habits Behavior problems affecting eating Poverty and food shortage Neglect, Disturbed parent-child relationship Mechanical feeding difficulties
6/11/2014 Failure to Thrive 22 Inadequate calorie intake 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
6/11/2014 Failure to Thrive 23 Inadequate absorption Hyperthyroidism Chronic infection- HIV, other immune diseases Hypoxemia-congenital heart defects and chronic lung disease
6/11/2014 Failure to Thrive 25 Defective utilization 6/11/2014 Failure to Thrive 26 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 ). IEM Associations Odors :- 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
6/11/2014 Failure to Thrive 32 6/11/2014 Failure to Thrive 33 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
6/11/2014 Failure to Thrive . 34 FTT - Classification Organic FTT Prenatal Causes Prematurity w/complications Toxic exposure Postnatal Inadequate intake Lack of appetite Inability to suck/swallow
6/11/2014 Failure to Thrive 35 Recap - Classification Failure to Thrive Organic Nonorganic Prenatal Postnatal Toxic Exposure Inborn errors Prenatal Postnatal Malnourished mother Abuse/Neglect 6/11/2014 Failure to Thrive 36 6/11/2014 Failure to Thrive Shannon Pittman, M.D. 37 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
6/11/2014 Failure to Thrive 38 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 6/11/2014 Failure to Thrive 39 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 6/11/2014 Failure to Thrive Shannon Pittman, M.D. 40 6/11/2014 Failure to Thrive 41 Why Do We Have to Talk About it at All? Personal Depending on current status in app. 7, 19, or 31 months you will sit for the ABFM (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.
6/11/2014 Failure to Thrive Shannon Pittman, M.D. 42 Take Home The keys to diagnosing FTT is finding the time to accurately measure and plot wgt/ht and then access the trend 6/11/2014 Failure to Thrive Shannon Pittman, M.D. 43 6/11/2014 Failure to Thrive 44 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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The Asymptotic Covariance Matrix of Maximum-Likelihood Estimates in Factor Analysis: The Case of Nearly Singular Matrix of Estimates of Unique Variances