3/16/2018. Normal patterns of growth Definition and causes of FTT Medical evaluation and management Effects of FTT Early intervention

Transcription

1 WI CAN Educational Series Hillary W. Petska, MD, MPH, FAAP Child Advocacy and Protection Services Children s Hospital of Wisconsin Normal patterns of growth Definition and causes of FTT Medical evaluation and management Effects of FTT Early intervention Infants typically lose 5-10% of birth weight, but regain by days Double birth weight by 5-6 months Triple birth weight by 1 year

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3 Infants should be breast or formula fed until 1 yo Breastfed babies should be given Vit D Solids can be started around 6 mos At 1 yo, transition to whole cow s milk (max: 24 ounces), low fat milk at 2 yo For kids > 1 yo, limit juice to 4-6 oz/d Not all diets are created equal. Cow milk or low iron formula iron deficiency Goat milk folate deficiency Raw milk infection risk Almond milk multiple deficiencies Fruit juice kwashiorkor Mostly diagnosed in children < 2 yo Seen in 5-10% of children in primary care settings Accounts for 1-5% of all referrals to children s hospitals

4 Prolonged cessation of appropriate weight gain compared to age/gender norms Weight < 3 rd percentile Decline of weight across 2 major percentiles in 6 months

5 Actual weight Ideal body weight x 100 % of Ideal Body Weight

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7 Decreased weight in proportion to length = FTT Inadequate nutrition: weight, then height, then head circumference affected

8 Decreased length in proportion to weight = endocrine abnormality Isolated cessation of head circumference growth = neurologic disorder

9 Proportionate decrease in weightfor-length with normal growth velocity FTT 3/16/2018

10 Intrauterine growth restriction, prematurity, genetic short stature, constitutional growth delay Conditional growth charts for children with altered growth patterns: Trisomy 21 (Down syndrome) Prader-Willi syndrome Williams syndrome Cornelia delange syndrome Turner syndrome Rubinstein-Taybi syndrome Marfan syndrome Achondroplasia

11 FTT is a sign, not a diagnosis Inadequate energy intake Inadequate nutrient absorption Increased energy requirements May be due to a medical condition, psychosocial reasons, or both

12 Prematurity Congenital anomalies Developmental delay Intrauterine exposures Lead poisoning Dietary beliefs/practices Any condition that results in inadequate intake, malabsorption, or increased metabolic rate Poverty Social isolation Domestic violence Substance abuse Mental health Knowledge deficits Stress Comprehensive history and exam can typically r/o medical causes Observation/history of feeding: Preparation of formula Oral-motor dysfunction Feeding environment Parent-child interaction

13 Hospitalization may be required: Diagnostic workup Severe malnutrition or dehydration Refeeding syndrome Protection Multidisciplinary team Feeding recommendations Nutrition education Referral for resources Close follow-up

14 Neglect Physical Environmental Supervisory Medical Emotional Educational Abuse Physical Sexual Poor linear growth Decreased brain growth Lower IQ Developmental delay Behavioral problems Increased risk of infection Poor wound healing Weak bones Death General appearance Behavior Stealing, hoarding food Disclosures Reports missing meals

15 Inadequate formula/food No clean dishes No electricity No running water Safety hazards Follow-up with PMD Medical records request WIC records Interview of child and/or siblings at a Child Advocacy Center Medical/investigator collaboration Failure to thrive is a common problem. Failure to thrive is due to inadequate nutrition, although the underlying cause is typically multifactorial. Failure to thrive has significant short- and long-term health consequences. Failure to thrive may be a sign of child neglect.

16 Block RW, NF Krebs. Failure to thrive as a manifestation of child neglect. Pediatrics. 116(5): ; DeNavas-Walt C, Proctor BD, Smith JC. U.S. Census Bureau, Current Population Reports, P Income, Poverty, and Health Insurance Coverage in the United States: U.S. Government Printing Office: Washington, DC; DiMaggio DM, Cox A, Porto AF. Updates in infant nutrition. Pediatr Rev. 38(10): ; Failure to thrive. In: Pediatric Nutrition: Policy of the American Academy of Pediatrics. 7th ed. Elk Grove Village, Ill.: American Academy of Pediatrics ; Gahagan S. Failure to thrive: A consequence of undernutrition. Pediatr Rev. 27(1):e1-11; Harper NS. Neglect: failure to thrive and obesity. Pediatr Clin North Am. 61(5): ; Homan GJ. Failure to thrive: a practical guide. Am Fam Physician. 94(4): ; Jaffe AC. Failure to Thrive: Current Clinical Concepts. Pediatr Rev. 32(3): ; Jenny C (ed). Child Abuse and Neglect: Diagnosis, Treatment, and Evidence. Saunders: St. Louis; Kirkland RT, Motil KJ. Etiology and evaluation of failure to thrive (undernutrition) in children younger than 2 years. UpToDate; The National Center on Addiction and Substance Abuse (CASA) at Columbia University. No safe haven: Children of substance-abusing parents. New York, NY: The National Center on Addiction and Substance Abuse (CASA) at Columbia University; 1999b. Osofsky JD. The impact of violence on children. Future Child. 9(3):33-49; Schwartz ID. Failure to thrive: an old nemesis in the new millennium. Pediatr Rev. 21(8): ; Tranchida, Vincent. The Pathology of Fatal Child Neglect. University of Wisconsin School of Medicine and Public Health. Monona Terrace Community and Convention Center, Madison, WI. 15 February Conference Presentation. I would also like to acknowledge Dr. Lynn K. Sheets and Dr. Angela L. Rabbitt who provided additional cases/slide content.