Failure to Thrive :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 1 Failure to Thrive Shannon Pittman, M.D. University of Mississippi Jackson, MS


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Slide 4:1/31/2009 Failure to Thrive Shannon Pittman, M.D. 4 http://www.peacecorpsonline.org/messages/messages/2629/1008996.html


Slide 5:1/31/2009 Failure to Thrive Shannon Pittman, M.D. 5 http://bluegoldfish.blogs.com/surface/2004/05/present_from_pr.html


Slide 6:1/31/2009 Failure to Thrive Shannon Pittman, M.D. 6 http://www.babybabyphoto.com/family/pages/02baby_flowers.htm


Slide 7:1/31/2009 Failure to Thrive Shannon Pittman, M.D. 7 http://www.kindersigns.com/images/corbis-black-baby.jpg


Objectives :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 8 Objectives To define failure to thrive (FTT) To identify major classification of FTT To discuss diagnostic workup of FTT To discuss treatment of FTT


Things We Will Not Cover :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 9 Things We Will Not Cover Geriatric FTT Am Fam Physician. 2004 Jul 15;70(2):248, 257. Rehabil Nurs. 2005 Jul-Aug;30(4):152-9 Adolescent FTT


Things We Will Not Cover :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 10 Things We Will Not Cover Other specific causes (e.g.) Congenital defects Celiac disease HIV/AIDS Metabolic disorders CHF (reference for Jenny) Prog Pediatr Cardiol. 2000 Sep 1;11(3):195-202.


Why Do We Have to Talk About it at All? :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 11 Why Do We Have to Talk About it at All? Personal Depending on current status in app. 9, 21, or 32 months you will sit for the ABFP (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.


Clinical Vignette :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 12 Clinical Vignette 15 month old admitted with lethargy from dermatology office Prior to admit, several days of decreased activity Med hx remarkable for eczema, treated with topical steroids


Clinical Vignette :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 13 Clinical Vignette Wgt and ht both below 5th percentile, but had grown along the 25th percentile until age 4mo Extensive erythematous plaques on her back, diaper region, thighs, and polpliteal fossa bilaterally


Clinical Vignette :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 14 Clinical Vignette What concerns you about this child What history questions should you ask What labs would you order How would you manage pt’s care


Okay, Tell Me What Happens Next - :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 15 Okay, Tell Me What Happens Next - Afternoon clinic 10 Patients scheduled Everyone of them showed up Your 5th pt is new & has a typed list It’s 4:00 and you are on pt 6 who happens to be a 9 mo well child


Slide 16:1/31/2009 Failure to Thrive Shannon Pittman, M.D. 16 http://www.cha.state.md.us/edcp/html/immpg.html


We’re not alone :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 17 We’re not alone In England, 54% of GP failed to diagnosis FTT Residency clinic, 41% with delayed dx Residency clinic, 29 dx, 100% dx incorrectly


FTT – Definition :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 18 FTT – Definition “Inadequate physical growth diagnosed by observation of growth over time using a standard growth chart”


Normal Growth :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 19 Normal Growth Average wgt 7 lbs (3kg) Double by 4 months, triple by 12 Grow 25 cm in length during 1st year Make sure you have the right chart Premature Breastfeeding www.cdc.gov/growthcharts


FTT Criteria :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 20 FTT Criteria Ht/Wgt less than 3rd to 5th percentile for age on >1 occasion Ht or Wgt falling 2 major percentiles Below 10th percentile for ht/wgt < 80% of ideal body wgt for age Head circumference important, but not part of FTT entity


FTT :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 21 FTT HISTORY ! HISTORY! HISTORY! Prenatal Feeding # oz needed in 24 hours Wgt (kgs) x 5 (need 100 kcal/kg/day) How formula prepared Good diet history (3 day journal) Bowel habits


FTT :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 22 FTT Physical Gomez Criteria <60 = severe; 61-75 = mod; 76-90 = mild Kwashiorkor – protein malnourishment Marasmus – caloric deficiency Short Stature Syndrome Constitutional Delay


FTT - Classification :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 23 FTT - Classification Organic FTT Pre/postnatal Nonorganic FTT (NOFT) Pre/postnatal Mixed (25%)


FTT - Classification :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 24 FTT - Classification Organic FTT Prenatal Causes Prematurity w/complications Toxic exposure Postnatal Inadequate intake Lack of appetite Inability to suck/swallow


FTT - Classification :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 25 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


FTT - Classification :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 26 FTT - Classification Nonorganic Prenatal Malnourished mother ? Lack of prenatal bonding Postnatal Poor feeding skills/disorder Dysfunctional family Difficult parent-child interactions Difficult Child Abuse/Neglect


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Recap - Classification :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 28 Recap - Classification


FTT - Workup :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 29 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


FTT – Treatment :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 30 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


Clinical Vignette :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 31 Clinical Vignette 15 month old admitted with lethargy from dermatology office Prior to admit, several days of decreased activity Med hx remarkable for eczema, treated with topical steroids


Clinical Vignette :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 32 Clinical Vignette Wgt and ht both below 5th percentile, but had grown along the 25th percentile until age 4mo Extensive erythematous plaques on her back, diaper region, thighs, and polpliteal fossa bilaterally


Clinical Vignette :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 33 Clinical Vignette What concerns you about this child What history questions should you ask What labs would you order How would you manage pt’s care


Summary: G.R.O.W.T.H. :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 34 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


Take Home :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 35 Take Home The keys to diagnosing FTT is finding the time to accurately measure and plot wgt/ht and then access the trend


Slide 36:1/31/2009 Failure to Thrive Shannon Pittman, M.D. 36 http://www.cha.state.md.us/edcp/html/immpg.html Afternoon clinic 10 Patients scheduled Everyone of them showed up Your 5th pt is new & has a typed list It’s 4:00 and you are on pt 6 who happens to be a 9 mo well child


Any Questions? :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 37 Any Questions? www.child.com/.../ baby_babble.jsp


References :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 38 References Listernick, R. (2004). Accurate feeding history key to failure to thrive. Pediatr Ann, 33:3, 161-9. Burgos, R., Jutte, D. (2000). Resident’s 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 gastroenterologist’s 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.


Thanks for Your Attention! :1/31/2009 Failure to Thrive Shannon Pittman, M.D. 39 Thanks for Your Attention! www.jade-designs.org/ tubetotin/jababybottom.gif