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
FTT- causes Ι. organic (5-10%) ΙΙ. Non organic
Complications UNDERLYING DISEASE malnutrition Reduced intake & absorbing nutrients loss of nutrients
FTT of organic origin - pathogenesis INSUFFICIENT CALORIES ABSORPTION AND INTAKE INCREASED CALORIES LOSS INCREASED REQUIREMENTS OR CONSUMPTION EXCESS
Non peptic FTT causes Chromosomal abnormalities Metabolic diseases Cardiac diseases Respiratory diseases CNS Urinary Tract Diseases Psychological causes
DIAGNOSIS Ι. History - personal - family - social ΙΙ. Dietary assessment ΙΙΙ. Laboratory tests
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?
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
COMMON CAUSES OF ORGANIC ORIGIN Celiac disease Eosinophilic gastroenteritis Inflammatory bowel disease Gastroesophageal reflux Oropharyngeal dysphagia
Gastroesophageal reflux
Allergic gastroenteropathy
Allergic gastroenteropathy ΙgE RAST to milk, egg, fish, wheat Skin test Patch test Special diet Hypoallergenic milk Montelukast (Singulair) corticosteroids 6-Merkaptopurine
Hypoallergenic milks Extended hydrolysate protein formula Alfaré, Almiron-Pepti Almiron-Pepti Pepti-MCT Peptamen junior elemental formula Neocate Neocate Advance Elemental 028
CELIAC DISEASE
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
The Celiac Iceberg Symptomatic Celiac Disease Manifest mucosal lesion Silent Celiac Disease Latent Celiac Disease Normal Mucosa Genetic susceptibility: - DQ2, DQ8 Positive serology
Histological findings Normal 0 Infiltrative 1 Hyperplastic 2 Partial atrophy 3a Subtotal atrophy 3b Total atrophy 3c Horvath K. Recent Advances in Pediatrics,, 2002.
Oropharyngeal dysphagia anatomical abnormalities neuromuscular abnormalities Clinical Signs impaired swallowing andchewing stridor aspiration Complications Unususal eating behavior Chemical pneumonia malnutrition
Crohn s Disease Terminal ileum Crohn s Disease
Ability Incentive willing unwilling able Normal behaviour Disorder unable organic disorder organic disorder? behaviour disorder?
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 : www.new.vis.com www.feeding.com V. psychologist: parents-child interaction and relationship support Eating is a very pleasant social experience
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
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
When it works, use it And if it doesn t, provoke it
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
AWARENESS PERSONAL HISTORY NO UNNEEDED TESTS NO EXAGGERATIONS!!
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