​Kembara Xtra - Medicine - Failure to Thrive

​Kembara Xtra - Medicine - Failure to Thrive 
Introduction 
Failure to thrive (FTT) is a symptom, not a diagnosis, of malnutrition in early children, manifested as stunted physical development that most often manifests as an inability to gain weight. Length and/or head circumference shortening may occur in extreme circumstances.
Weight or body mass index (BMI) for age below the 5th percentile on more than one occasion OR weight that drops two or more major percentile lines on standard growth charts OR weight-for-length below the 5th percentile are all commonly used clinical definitions of FTT.
Children at risk of FTT should be identified using multiple anthropometric characteristics rather than just one.

Concerns for Children
Different growth patterns are seen in kids who have been diagnosed with genetic disorders, had IUGR, or were born prematurely.
● In the first two years of life, 25% of children will fall below two major percentile lines in either weight or height. When these kids don't attain their full height and weight potential, it's called constitutional growth delay (when their bone age is older than their chronological age). These infants do not get FTT and instead develop normally along their new percentile after the transfer.

The Incidence of Epidemiology
Six months to a year is the most common age range, with most children being less than 18 months.

Prevalence
Ten percent or more of kids who visit the doctor show symptoms of development failure.
FTT accounts for 1-5% of all pediatric hospital admissions and is more common in low-income children.

The Cause and Effect Pathophysiology 
Overconsumption of calories relative to energy used can be caused by four main factors:
Low calorie intake is the most common cause of malnutrition.
- Not taking in enough calories
Excessive energy output
Incorrect Application
Although FTT was once divided between organic and inorganic causes, researchers have since discovered that the majority of cases have many contributing factors.
● Pathophysiology (with examples) can be used to classify the many causes of FTT.
Poor feeding habits (e.g., excessive juice, restrictive diets), mechanical problems (e.g., oromotor dysfunction, congenital anomalies, GERD, CNS, or PNS anomalies), oral aversion, poverty, neglect/abuse, poor parent-child interaction, caregiver feeding style, and other factors can all contribute to an infant's insufficient food intake.
Necrotizing enterocolitis, small bowel syndrome, biliary atresia, liver illness, cystic fibrosis, coeliac disease, milk protein allergy, vitamin/mineral deficiencies, and environmental enteric dysfunction are all causes of malabsorption.
Conditions include hyperthyroidism, congenital/chronic cardiac disease, HIV/AIDS, immunodeficiencies, cancer, kidney disease, and obstructive sleep apnea are associated with higher medical bills.
Congenital infections (TORCH: toxoplasmosis, other agents, rubella, cytomegalovirus, herpes simplex) and metabolic abnormalities (such as diabetes) are examples of improper use.

Psychosocial Risk Factors Poverty, parent(s) with mental health disorder or cognitive impairment, inadequate parenting skills or hypervigilant parents, households with distinctive health/nutritional beliefs, physical or emotional abuse, substance misuse, and social isolation.
IUGR (symmetric or asymmetric), congenital anomalies, oromotor dysfunction, premature or unwell newborn, infant with physical deformity, acute or chronic medical disorders, developmental delay, lead poisoning, anemia, and so on are all things that pose health hazards.

Planning for a Baby
Prematurity, IUGR, and intrauterine exposures are all associated with FTT.


Prevention 

Normal feeding and parenting techniques should be taught to new parents.
Women, infants, and children should have access to supplemental feeding programs; high-risk youngsters should have more frequent checkups.


Because most cases of FTT are caused by underfeeding or incorrect feeding, a meticulous and detailed history is almost always sufficient for successful therapy.
Exposures during pregnancy and development
Family history: height of parents and growth patterns of siblings, presence of chronic diseases, genetic disorders, developmental delay, and consanguinity Medication history, including complementary and alternative medications Past medical history: acute/chronic disease affecting caloric intake, digestion, absorption, or causing increased energy need or defective utilization
● Social history: family composition, socioeconomic status, hygiene practices, child-rearing beliefs, stressors, parental depression, and unusual behaviors during feeding Dietary history: breastfeeding or formula feeding; timing and introduction of solids; who feeds the child, when, and where; placement during feeds; amounts consumed/caloric intake; beverages consumed; snacking; vomiting or stooling associated with feeds; oral aversions or unusual behaviors during feeding


Analyses in the Clinic 

It is recommended to use multiple anthropometric criteria for diagnosis rather than just one, and that measurements be taken at different times.
The NCHS's reliable measurements of height, weight, and head circumference (available at https://www.cdc.gov/growthcharts/)
Breastfed infants may do better according to the WHO's growth charts (http://www.who.int/ childgrowth/ standards/ en/).

● This test should evaluate the following:
Warning signs of severe malnutrition or dehydration
Estimated Gomez classification of malnutrition severity: When a person's actual weight is compared to their ideal weight for their age (the 50th percentile), the difference can be classified as severe (60%), moderate (61-65%), or mild (76-90%).
- Disfigurement and asymmetry
Cognitive state (awareness, receptiveness)
Look for bonding and social/psychological cues from caregivers, as well as any symptoms of physical abuse or neglect.

Diagnostic Distinction 
Sort things out according to rates of development.
Low birth weight with normal linear development and head circumference and low birth weight with decreased linear growth and decreased head circumference (without neurologic symptoms) are the two most common presentations of FTT.
Consider genetic possibilities (constitutional short stature or growth delay), genetic syndromes, teratogens, and endocrine diseases if low linear growth with normal weight for length or low linear growth and proportionately low weight and decreased head circumference.
Consider TORCH infections, genetic disorders, teratogens, and brain injury (i.e. hypoxic/ischemic) in the case of microcephaly with obvious neurologic symptoms and poor growth related to a presumed neurological condition.

Lab results It is advisable to address nutritional issues first before undergoing thorough labs and other workup, as they are effective in only about one percent of instances.
Initial Lab and Imaging Tests
The results of the history and physical examination, as well as the patient's age, should dictate which tests are prescribed.
Initial evaluation tests that are typically considered:
Electrolytes, BUN/creatinine, liver function tests, TSH, free T4, urinalysis, and a culture of the urine

 Other tests as needed based on the history and physical: - Amylase/lipase, serum zinc level, iron studies, IGF-1, karyotype, genetic testing, sweat chloride test, stool for ova and parasite or fat/reducing substances, guaiac, 1-antitrypsin and elastase, radioallergosorbent test for IgE food allergies, tissue transglutaminase and total IgA (
Bone age and skeletal dysplasia can be determined by an X-ray of the hand and/or wrist.

Additional Evaluations & Cautious Thoughts
Obtaining an accurate record of calorie consumption necessitates keeping a prospective 3-day food diary.
Clinician visits to homes to observe infant feeding, caregiver interaction, and home environment; observation of breastfeeding and/or formula preparation to ensure adequacy and offer of instruction; referrals to appropriate specialists, such as dietitians, occupational therapists, physical therapists, speech therapists, social workers, developmental specialists, psychiatrists, psychologists, visiting nurses, lactation consultants, and/or child protective services, as needed.

Tests and Other Methods of Diagnosis
Skeletal survey, bone age, swallowing studies, small bowel follow-through for suspected oromotor dysfunction, GERD, structural abnormalities, brain imaging for microcephalic and/or neurologic findings on examination, echocardiogram for auscultated murmur, referral to specialist based on results of initial evaluation (e.g., endocrinology, gastroenterology).

Management 
Care for the source of the problem.
Infants and children with FTT should have their interactions with their caregivers assessed.
Nutritional guidance according to the patient's age should be offered.
– The goal is to increase nutrient intake such that catch-up growth (a weight gain of two to three times the average for age) can occur.

To determine energy requirements, take the daily recommended intake for your age and multiply it by 1.5.
The recommended dietary allowance (RDA) for age (kcal/kg) ideal weight for height (kg) / actual weight (kg) is another way to determine how many calories a child needs to eat each day to catch up on growth.
If you want to gain weight, you should try increasing your calorie consumption.
Maximize assistance for nursing; think about adding supplements.
Formulations with more calories
Rice grains or fats added to existing foods.
Reduce milk consumption to between 24 and 32 ounces daily.
Stay away from the drink and juice.
Vitamins, minerals, and other dietary supplements
Provide help for issues affecting the household as a whole (such as WIC, food stamps, and other forms of temporary aid).

Diarrhea, malabsorption, low potassium levels, and low phosphate levels are only few of the side effects of a sudden calorie binge.
As a result, formulae with a calorie density of >24 kcal/oz should be avoided.
Over the course of 5–7 days, you should gradually raise your caloric intake to your target level.
The delayed growth should accelerate in the following 2–7 days.
To regain lost mass and height, accelerated growth should be maintained for 4–9 months.
Take into account a referral from a visiting nurse and an assessment from social services to see what help your family may be eligible for.

Referral 

Aid from multiple fields is always welcome. When a primary care physician (PCP) does not have access to specialized services like dietary counseling, psychological evaluations, physical therapy, occupational therapy, or speech therapy, it may be beneficial for a child to visit a specialized multidisciplinary clinic.

Medical Interventions 
In extreme circumstances, a gastrostomy or nasogastric tube feedings may be considered.

Admission 

Although most cases of FTT may be treated without hospitalization, admission may be necessary if either: - Outpatient therapy fails; or - Severe dehydration or malnutrition is present.
Abuse or neglect is suspected because...
There is worry that the child's mental health will suffer as a result of the circumstances.
– Some children experiencing catch-up growth will be affected by nutritional recovery syndrome:
Sweating, a high core temperature, hepatomegaly (increased glycogen deposits in the liver), widened cranial sutures (brain growth > bone growth), longer stretches of sleep, restlessness, and mild hyperactivity are all symptoms.
– In addition, diarrhea and malabsorption may occur together in the beginning.

The delayed growth should accelerate in the following 2–7 days. If this is not realized, then we must reconsider the underlying causes.

Frequent visits over a lengthy period of time as part of a long-term follow-up plan (every 2–4 weeks initially, then 1–2 months if substantial progress is made).
Children who have had FTT in the past are more likely to get it again.
The proper authorities must be contacted if the family does not comply.

​Diet
What a "normal" kid needs to eat:
When breast-feeding, make sure to feed your baby at the right intervals and for the right amount of time (120 kcal/kg/day for the first 6 months, then 95 kcal/kg/day).
– Breast milk and/or formula should be continued between 6 and 12 months, but pureed foods should be introduced many times a day.
Avoid juice and soda and feed in a social setting while still giving your toddler three balanced meals and two healthy snacks each day.
● Normal rate of weight increase for your age:
Counsel parents about the need of avoiding "food battles," which can exacerbate the problem, for children aged 0-3 months (26-31 grams per day), 3-6 months (17-18 grams per day), 6-9 months (12-13 grams per day), 1-3 years (7-9) and older (9-12 grams per day).
Parents need to be taught the value of calm, social mealtimes, the correct way to prepare infant formula and other foods, and how to feed their child properly.


The prognosis for children with FTT is mixed; they are at a higher risk for future undernutrition, overnutrition, and eating disorders, yet many children with FTT improve their diet sufficiently with care.