Failure to thrive - Definition. age and gender

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2 Failure to thrive - Definition Weight or weight for height (N / M) less than two SDs below the mean for age and gender Weight curve has crossed more than two percentiles (NCHS), after having achieved a previously stable pattern

3 FTT- causes Ι. organic (5-10%) ΙΙ. Non organic

4 Complications UNDERLYING DISEASE malnutrition Reduced intake & absorbing nutrients loss of nutrients

5 FTT of organic origin - pathogenesis INSUFFICIENT CALORIES ABSORPTION AND INTAKE INCREASED CALORIES LOSS INCREASED REQUIREMENTS OR CONSUMPTION EXCESS

6 Non peptic FTT causes Chromosomal abnormalities Metabolic diseases Cardiac diseases Respiratory diseases CNS Urinary Tract Diseases Psychological causes

7 DIAGNOSIS Ι. History - personal - family - social ΙΙ. Dietary assessment ΙΙΙ. Laboratory tests

8 DIETARY ASSESSMENT Type of food eaten? Time srent over a meal? Number of meals and snacks? Breastfeeding enough? Special diet? Allergy; Intolerance? Unusual eating behavior?

9 Laboratory tests immunoglobulines antigliadin antibodies (AGA) antiendomysial antibodies (ΕΜΑ) antitransglutaminase antibodies (ttg( ttg) urine organic acids karyotype growth hormone count thyroid function cardiovascular tests Urea breath test 13 (-UBT) Sweat test Abdomen U/S Brain CT MRI Ro GI - urinary tract 24hrs PHmetry Endoscopy

10 COMMON CAUSES OF ORGANIC ORIGIN Celiac disease Eosinophilic gastroenteritis Inflammatory bowel disease Gastroesophageal reflux Oropharyngeal dysphagia

11 Gastroesophageal reflux

12 Allergic gastroenteropathy

13 Allergic gastroenteropathy ΙgE RAST to milk, egg, fish, wheat Skin test Patch test Special diet Hypoallergenic milk Montelukast (Singulair) corticosteroids 6-Merkaptopurine

14 Hypoallergenic milks Extended hydrolysate protein formula Alfaré, Almiron-Pepti Almiron-Pepti Pepti-MCT Peptamen junior elemental formula Neocate Neocate Advance Elemental 028

15 CELIAC DISEASE

16 immunoglobulins antitransglutaminase antibodies IgA antiendomysial antibodies antigliadin antibodies (AGA: IgG, IgA*) unreliable Small bowel biopsy: celiac disease seropositive celiac disease seronega negative suspects *(In IgA CELIAC DISEASE DIAGNOSTIC PROCEDURE IgA deficiency or <5 years age, antibodies are unreliable) Before diagnostic tests: Free Diet

17 The Celiac Iceberg Symptomatic Celiac Disease Manifest mucosal lesion Silent Celiac Disease Latent Celiac Disease Normal Mucosa Genetic susceptibility: - DQ2, DQ8 Positive serology

18 Histological findings Normal 0 Infiltrative 1 Hyperplastic 2 Partial atrophy 3a Subtotal atrophy 3b Total atrophy 3c Horvath K. Recent Advances in Pediatrics,, 2002.

19 Oropharyngeal dysphagia anatomical abnormalities neuromuscular abnormalities Clinical Signs impaired swallowing andchewing stridor aspiration Complications Unususal eating behavior Chemical pneumonia malnutrition

20 Crohn s Disease Terminal ileum Crohn s Disease

21 Ability Incentive willing unwilling able Normal behaviour Disorder unable organic disorder organic disorder? behaviour disorder?

22 FTT- treatment Ι. Pediatrician : Evaluation of the medical history and clinical signs. Consider the specialist ΙΙ. Gastroenterologist: ΙΙΙ. Dietician : IV. Speechtherapist: Diagnosis and intervention (Modified barium meal Education) Utilities ies : V. psychologist: parents-child interaction and relationship support Eating is a very pleasant social experience

23 Diet evaluation - Procedures Calories intake (72hr hrs diary) 50% age basic requirements HOW? Milk enrichment and supplementation (0.8-1Kcal/ml) caloreen 1gr:4Kcal (density( έως 8%) maxijul 1gr: 4Kcal liquigen (MCT-oil): 1ml: 4.5Kcal calogen (LCT-oil) 1ml: 4.5Kcal Hypercaloric formulas (1Kcal/ml) Hypoallergenic hypercaloric formulas

24 Organic origin Non organic origin Therapeutic procedures CALORIC EVALUATION DIET ENHANCEMENT RESPONSE CONTINUE NO RESPONSE SWALLOWING DISORDER PROBABILITY SPESIALISTS TEAM RESPONSE NO RESPONSE CONTINUE INVESTIGATION tube feeding stoma

25 When it works, use it And if it doesn t, provoke it

26 Selecting nutritional support method When oral feeding is insufficient GI tract is available either anatomically or functional GI tract is not available Enteral feeding Parenteral feeding Gastric infusion Enteral infusion

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29 AWARENESS PERSONAL HISTORY NO UNNEEDED TESTS NO EXAGGERATIONS!!

30 We don t need sophisticated experiments to conclude that a child dies from lack of food Reversely, centuries passed in order to realize that children are lost from lack of affection and love!! Louise S. Kaplan, 1995