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Failure to Thrive

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by

Caitlin Schmidt

on 2 May 2013

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Transcript of Failure to Thrive

Normal
Growth SGA The Prem Infant Failure to thrive GOR BF Feeding Most children grow predictably
Term infants:
Regain BW by 10-14 days
Gain 30g/day until 3 months
Gain 20g/day from 3-12 months
BW x 2 by 4 months; x 3 by 1 year
Gain 2kg/year from 2 years to puberty
OFC 1cm/month during 1st year
Brain weight x 2 at 4-6 months; x 3 at 1 year Small for gestational age (SGA): Birthweight or length 2 SD below the mean for the reference population
2 SD below the mean = 2.3 centile
Often described as <10th centile (or <5th centile) Intrauterine growth retardation (IUGR): Diminished fetal growth velocity as documented by at least 2 intrauterine growth assessments
Indicates a pathophysiological process occurring in utero that inhibits fetal growth
A child born SGA has not necessarily suffered from IUGR, and infants who are born after a short period of IUGR are not necessarily SGA Is a problem rather than a diagnosis
Usually recognised within first 1-2 years of life
Describes failure to gain expected weight
weight < 3rd centile for age and sex, or
crosses > 2 major percentile lines (eg, 75th to 25th)
Length & head circumference are normally not affected or to a lesser degree Failure to Thrive 24-32 weeks GA, followed up to 8 years
SGA if < 10th centile, mildly SGA if 10-20th centile, AGA if >20th centile
Mortality rates for infants born 24-28 weeks GA:
AGA 30%
mildly SGA 42%
SGA 62% EPIPAGE study (France) For infants born 29-32 weeks GA and SGA:
Higher risk mortality (aOR 2.79, 95% CI 1.50-5.20)
increased cognitive difficulties (aOR 1.73, 95% CI 1.12–2.69)
increased inattention-hyperactivity symptoms (aOR 1.78, 95% CI 1.10 –2.89)
increased school difficulties (aOR 1.74, 95% CI 1.07– 2.82)
Even mildy SGA infants had increased risk for cognitive difficulties and
behavioral difficulties Neurologic Outcomes at School Age in Very Preterm Infants Born With Severe or Mild Growth Restriction Isabelle Guellec, Alexandre Lapillonne, Sylvain Renolleau, Marie-Laure Charlaluk, Jean-Christophe Roze, Stéphane Marret, Rachel Vieux, Kaminski Monique, Pierre-Yves Ancel and the EPIPAGE Study Group Pediatrics 2011;127;e883 EPIPAGE study (France) The Infant Health and Development Program (IHDP) Study Impact of Prenatal and/or Postnatal Growth Problems in Low Birth Weight Preterm Infants on School-Age Outcomes: An 8-Year Longitudinal Evaluation Patrick H. Casey, Leanne Whiteside-Mansell, Kathleen Barrett, Robert H. Bradley and Regina Gargus Pediatrics 2006;118;1078 Outcome of SGA and AGA Infants Born Before 27 Weeks of Gestation.
Claudette Bardin, Phyllis Zelkowitz and Apostolos Papageorgiou Pediatrics 1997;100;e4 Can we make a difference in the NICU? Infants born 500-1000g, divided into quartiles by weight gain/day Do we Succeed in the NICU? Richard A. Ehrenkranz, Anna M. Dusick, Betty R. Vohr, Linda L. Wright, Lisa A. Wrage and W. Kenneth Poole. Growth in the Neonatal Intensive Care Unit Influences Neurodevelopmental and Growth Outcomes of Extremely Low Birth Weight Infants. Pediatrics 2006;117;1253 24 371 infants born 23-34 weeks GA
Reviewed infants with weight, height or HC ≤ 10th centile
Extrauterine growth restriction common
weight 28%
height 34%
HC 16%
Reese H. Clark, Pam Thomas and Joyce Peabody. Extrauterine Growth Restriction Remains a Serious Problem in Prematurely Born Neonates. Pediatrics 2003;111;986 NICU issues for SGA versus AGA infants born less than 27 weeks GA:

21% of cohort defined as SGA
similar rate of RDS
more prolonged need for ventilatory support
higher risk chronic lung disease and home oxygen
greater risk of ROP
more likely to require PDA ligation Factors associated with SGA 1-5 % of all referrals to paediatric departments
In some populations, ±20-50% go undiagnosed
Organic FTT rare and difficult to distinguishable from
non-organic FTT
FTT is often the result of undernutrition
Undernutrition ≠does not equal neglect
FTT children 4 x more likely to be abused
±2-10% of all cases need DOCS
FTT is best managed in the community FTT is an important problem Chronic illness
cardiac disease
liver failure
renal failure
endocrine disorders
infections
anaemia Excessive utilisation of energy Primary management:
Simple dietary and behavioural advice
Family support Specialist management:
Dietician
SLT
Investigations Social work
input DCS Healthy term and preterm infants have physiological GOR
Asymptomatic preterm infants have GOR 3-5 times per hour
Recent NICHD network study showed 25% of ELBW infants discharged on anti-GOR medications
UK questionnaire to neonatologists: GOR considered diagnostic concern in 1 in 5 patients
non-specific symptoms
supine body position, large fluid intake (∼14L/day in an adult)
transient lower oesophageal sphincter relaxations (TLESRs) pH studies on 36 preterm infants
14 symptomatic for GOR
TLESR equally common in symptomatic and asymptomatic infants
Almost all GOR associated with TLESR
Not all TLESR associated with GOR
Symptomatic infants had higher rate of acid GOR (16.5% vs 5.9%)
Other factors
NGT, delayed gastric emptying
Definitive investigations difficult Omari T, Barnett C, Benninga MA et al. Mechanism of gastroesophageal reflux in premature infants with chronic lung disease.
J Pediatr Surg 1999;34:1795-8 human studies show laryngeal fluid increases swallowing not apnoea
1% of infants had apnoea associated with GOR, although parents reported GOR after feeds in 42% of infants
Preterm study: no increase in events within 20sec after GOR episode
0.19 vs 0.25 apnoeas/min; no increase in desaturation or bradycardia
Other studies have shown some association between apnoea and GOR, or apnoea and TLESRs.

AOP and GOR are common, share risk factors but likely not causally linked Few studies on GOR and FTT
Case control study:
weekly weight gain and caloric intake similar between infants with or without clinically significant GOR
Infants with GOR had longer hospital stays

Recommend:
ensure adequate intake for preterm infants
rule out other causes of FTT first Failure to thrive Potential consequences of GOR Apnoea (AOP) Obese mothers more often felt uncomfortable breastfeeding in public at 3 months.
Fewer obese mothers perceived that their milk supply was sufficient at 1 month and 3 months.
Despite greater breastfeeding difficulties, obese mothers were less likely to seek support for breastfeeding in the first 3 months postpartum. Elise Mok, Clarisse Multon, Lorraine Piguel, Emmanuelle Barroso, Valérie Goua, Patricia Christin, Marie-José Perez and Régis Hankard. Decreased Full Breastfeeding, Altered Practices, Perceptions, and Infant Weight Change of Prepregnant Obese Women: A Need for Extra Support. Pediatrics 2008;121;e1319 Charlotte M. Wright, Kathryn N. Parkinson and Robert F. Drewett. How Does Maternal and Child Feeding Behavior Relate to Weight Gain and Failure to Thrive? Data From a Prospective Birth Cohort. Pediatrics 2006;117;1262 Millenium Infant Study Weight gain to 6 weeks related to appetite and oromotor dysfunction

Appetite rated at 6 weeks and 12 months both independently predicted weight gain to 12 months
32% of Low appetite infants had faltering weight

Some avoidant eating behaviour seen in most children by 12 months
no relationship with weight gain after adjustment for appetite
The extent to which caregivers responded to food refusal was a significant inverse predictor of weight gain, even after adjustment for appetite Nutritional:
“what”, “how often”, “how easily”
? vegetarian, ? allergies
Dietician input
Psychosocial
Pregnancy, parity
Parent mental health & cognitive function
Social circumstances, employment, support
Parental height
Recurrent infections, vomiting, diarrhoea, respiratory symptoms History Growth parameters
General examination
Abnormal development
Dysmorphic features
cleft palate or abnormal sucking movements
Hypotonia or spasticity
Chronic cardiac or respiratory disease
Abdominal distension or organomegaly
muscle wasting
Severe diaper rash
signs of neglect or abuse Examination Generally “wait-and-see” approach, unless evidence of:
Abuse
Organic disease
Severe undernutrition Investigation Cases 8 month boy with FTT
Seen a number of times in POPD
Elective admissions for further investigation but premature discharge
Difficult full assessment
Poor weight gain since 6 months
Vomiting
daily, small volume, food, post feeds
Normal Development
No other symptoms Little Johnny Elective C/S at 35/40 (breech)
Pregnancy:
Gestational diabetes (diet), hypertension
3 days in hospital because of BF problems
EBM until 6 months
Commenced S26 at 6 months
120ml 5-6x day
90 minutes to finish feeds
Solids commenced at 6 months (fussy) Mum at home, dad works irregular hours
Few social supports
8yr old brother
normal growth
good eater when young
Family conflict about infants growth
Reluctance for admission +++
Normal examination except FTT Urea, Cr & electrolytes, calcium & phosphate
FBC
CRP, ESR
TFTs
Urine Stool (MC&S and RS)
LFTs
Mild iron deficiency
coeliac screen negative
Normal CXR Failure to thrive secondary to inadequate oral intake

Management
Nasogastric tube inserted
R/V by dietician
Weekly R/V in outpatients Diagnosis 1 year old boy
unwell 1/12, marked loss of weight but no fever
poor appetite, listless, weak
abdominal distention
intermittent vomiting, non bilious
intermittent constipation, very “gassy”
bowel motions large, bulky, foul smelling
Dietary Hx
formula S26 from birth
rice cereal at 4/12, bread & pasta at 6/12, weetbix at 10/12
cow’s milk at 11/12 Tiny Tim Development:
sitting without support, crawling
weight bearing with support, lately not crawling or standing
babbling, few words
Family Hx
mother described as “picky eater”
maternal grandmother: Hodgkin’s Lymphoma
paternal grandfather: Gastric ulcer Irritable, emaciated, pale +++
Reduced subcutaneous fat, poor muscle bulk
Distended abdomen
No shifting dullness or organomegaly
No clubbing
No rash
Some cervical & inguinal lymph nodes FBC: Hb 104, WCC 15.1, Plt 764, MCV 69
Urea, Cr, electrolytes: normal
LFT: Albumin 23, Total Protein 50
Coags: normal
Stools: No growth/crystals/globules
Total IgA < 0.07g/L
TTG IgA mildly elevated
Small intestinal biopsy confirmed coeliac disease P. Wee 6 months old girl
first born child
parents on 1st & 3rd centiles
Birth weight 2.9 kg
Length 46 cm
Breast fed until 3/12
Cow’s milk formula
Solid foods at 4/12
Normal examination Junior A Infant Growth Behaviour Lack of appetite
chronic illness or anaemia
psychosocial disorder
Food not available
type or volume of food not appropriate
feeding technique, parental-infant interaction problems
withholding of food Inadequate food intake Reduced absorbtion or digestion of nutrients Pancreatic insufficiency (cystic fibrosis)
Loss or damage to villous surface: inflammation, coeliac disease


Vomiting
gastro-intestinal: GOR, obstruction
CNS: intracranial pressure, drugs
systemic illness: infection, metabolic disorders
Malabsorption/diarrhoea
coeliac disease, IBD, CF, colitis
Renal losses
renal failure/RTA, diabetes



Chromosomal or genetic abnormality
Metabolic or endocrine disorder Excessive loss of nutrients Inability to properly utilise ingested nutrients Investigations
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