Failure to thriveFailure to thrive

Diagnostic criteria and diff dxDiagnostic criteria and diff dx

H and P key pointsH and P key points

Dx testing in the evaluationDx testing in the evaluation

18 month female 18 month female difficulty gaining weightdifficulty gaining weight

• 2 previous visits, noted to have slowing in her weight gain

• Weight previously followed 75% slipped to 50 th

• This visit wt below the 5 th percentile for age

• Ht has continued along the same 50 th % trajectory

Scope of the problemScope of the problem

• FTT used to describe children with poor growth; serial measurements of wt, ht, ofc compared with population growth averages

• Growth over time helpful; constitutional delay children may grow consistently below (but parallel) curves

• Wasting refers to deficit in wt to ht or type 1 FTT

The broad criterionThe broad criterion

• Decrease in wt, ht or ofc percentiles that crosses 2 major trajectories in downward trend

• Weight for length below the 5th percentile (in absence of serial measurements)

• Decreased mid-arm circumference-to-head circumference ratio

• Weight below the 5 th percentile

Non-organic causesNon-organic causes

• Family dysfunction (divorce, spousal abuse, chaotic family style)

• Parental dysfunction (psychosis, drug or alcohol abuse)

• Parent-child interaction dysfunction• Isolation or lack of support (no family or

extended family)• Lack of preparation for parenting or ignorance• Child abuse/neglect• Unusual food fad diet

Organic causes of FTTOrganic causes of FTT

• Decreased caloric intakepoor feeding (neuro/feeding disorders)decreased appetite (chronic disease)vomiting (gerd, ps, icp)chronic infection (giardea,etc)mucosal abnormalities (celiac, ibd)pancreatic insufficiency (cf, etc)enzyme deficiencies

allergic gastroenteropathy

FurthermoreFurthermore

• Increased losses and metabolic disorders

protein losing enteropathy

metabolic disorders

bile salts def

lympangiectasia

• Increased caloric requirments

HyperthyroidismChronic

diseases: chd, chronic resp disease, malignancy, ibd,

immunodeficiency

With apologies for the listWith apologies for the list

• Parents and child interact warmly in office

• Family hx noncontributory

• Diet reasonably varied, good quantity

• Parents are stable, good mental health, no drugs or abuse suspected

History and physicalHistory and physical

• Gives direction to the work; AJDC study of details the futility of investigations unless suggested in the h and p evaluation

• 3 day diary always helpful in the history to corroborate the adequacy of caloric intake

• Stool consistency may indicate malabsorption (malodorous, foamy, floating for fat malabsorption)

• Vomiting hx directs toward broad differential

Physical examPhysical exam

• Malnutrition: hair texture and color, skin

• Respiratory: lung sounds, clubbing

• Heart disease: murmurs, PMI heave, sweaty babies

• GI dis: inc L/S, perianal disease, guiac

• Neuro: wasting, abnl tone

The history continuesThe history continues

• Parents report pt is comfortable, 3 loose stools a day

• FT, SVD, 3750 gm.

• Breast to 6 months then formula; baby foods at 5 months; good mix of table foods

• No sig infections, no hosp

• Northern european descent; neg fam hx

The asthenic toddlerThe asthenic toddler

• Thin child in no distress

• General exam is normal

• Abdomen is soft nontender; perhaps slightly distended

• Neuro reveals interactive child, wiry, nml tone, nml reflexes

• The 3 days diary gives detailed account of foods and milk

• Look for excessive fluid intake, inappropriate milk or juice intake

• Basic labs: CBC, ESR, chem 7 (bun/cr, CO2), TPro

• As indicated: stool fat, occult blood, white cells, O&P or elisa for giardia

• As indicated: sweat, HIV, TB skin test

H & P: loose stools?? H & P: loose stools??

• The loose stools raises suspicion for infection and/or malabsorption

• Stool for O & P, elisa giardia, fecal fat, white cells

• Sweat chloride and celiac antibodies

Los resultadosLos resultados

• Celiac panel is positive

• Transglutaminases (if ordered) 195 units (0-20 nml range)

• Antiendomysial antibody is pos at 1:40 (nml less than 1:20)

Celiac diseaseCeliac disease

• Production of local and systemic antibodies

• Ig A antireticulin Ab and IgA antiendomysial Ab are specific markers for celiac disease

• Tissue transglutaminase Ab has recently been identified as the autoantigen recognized by endomysial Ab (most sensitive marker)

Referral to GIReferral to GI

• Esophagogastroduodenoscopy

• Bx of small bowel consistant with celiac disease

Celiac diseaseCeliac disease

• Intolerance to gluten of wheat, barley, rye, and oats

• More common in whites, nearly nonexistent in Africa, Asia

• 1:300 in western Ireland, 1:5000 in Minnesota, 2 % in Sweden and 1 in 50 in a high risk population (GI clinic waiting room)

More??More??

• Familial tendency follows polygenic inheritance• Strong association between celiac dis and HLA

antigens• Interaction between genetics and environmental

exposure• Wheat gluten is water insoluble protein left after

starch extraction• Gliadin, a complex protein, is a fraction of the

wheat gluten• T cell response to gluten in the lamina propria

Utility of endoscopy and BxUtility of endoscopy and Bx

• Small bowel mucosal flattening

• Lymphocytic infiltration in lamina propria, elongation of the crypts, villous atrophy

Treatment of CeliacTreatment of Celiac

• Mainstay is avoidance of gluten

• Quite difficult to achieve in typical Western diet

• Catch up growth can be rapid and complete in 15 months after effective avoidance

Sweaty babiesSweaty babies

• 10 week old male with poor weight gain

• Sweaty babies suggests adrenergic overdrive

• Gallop rhythm, heavy PMI

• Liver edge is down

• Radiograph of chest

6 month comes pale and below 5 th 6 month comes pale and below 5 th percentpercent

• Renal lesions are “occult”

• Bilateral abdominal masses

• Cr 5.8

• Posterior urethral valves

Is it a real condition?Is it a real condition?

• 15 month old female falls off the curves

• CO2 12 on first determination; 15 on repeat

• Proximal absorption defect seen in toddler years

• Responds to large doses of bicarb (10 per kg divided)

• Appetite improves and weight gain is seen

Newborn screeningNewborn screening

• 6 month old comes in with weight down

• She appears puffy

• Rsv then chronic congestion

• T Pro depressed

• False negative from NB screen