FTT and PEM

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FAILURE TO THRIVE

1

BY :

ABDUL HAFIZ ALIAS060100846



Definition

term is widely used to describe inadequate growth in early childhood

no consensus has been reached concerning the specific anthropometrical

criteria to define this description height or weight less than the third to fifth

percentiles for age on more than one occasion

height or weight measurements falling 2major percentile lines using the standard growth charts of the National Center for Health Statistics (NCHS) in a short time.

tr ue malnutrition (weight <80% of ideal body weight for age)

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Normal growth in term

infants

3

Average birth weight for a term infant is 3

.3

kg. Average birth weight for a term infant is 3

.3

kg.

Weight drops as much as 10% in the first few days of life Weight drops as much as 10% in the first few days of life



Weight/dayWeight/day g/dayg/day

00--3

3

mthsmths 2626--3

13

133--6 mths6 mths 1717--1818

66--9 mths9 mths 1212--1313

99--12 mths12 mths 99

11--3 yrs3 yrs 77--99

44--6 yrs6 yrs 66

Height/yrHeight/yr cm/yearcm/year

11st st 2525

22ndnd 12.512.5

44thth

-- onset onset of pubertyof puberty 55--66

PubertyPubertyonwardsonwards

1212

4



Head Head

circumferencecircumference

(year )(year )

Average Average

(cm)(cm)

BirthBirth 3535

11stst

4747

22ndnd 4949

66thth 5555

upperupper--toto--lower bodylower bodysegment segment

ratioratio

Average(cm) Average(cm)

BirthBirth 1.71.7

11st st 1.31.3

77thth 1.01.0

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Normal growth in

premature infants

When plotting growth charts for premature babies, a "corrected age"should be used.

Corrected age : subtracting the number

of weeks of prematurity from the postnatal age Catch-up growth is attained, at

approximately age 18 months for head circumference, age 24 months for weight, and age 40 months for height,

then the normal growth charts can be used. In some premature babies with very

low birth-weight, catch-up growth does not occur until early school age.

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ETIOLOGY

NON ORGANIC ORGANIC COMBINATION

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NON ORGANIC

Poor feeding or feeding-skills disorder

Dysfunctional family interactions

Difficult parent-child interactions

Lack of support (eg, no friends, no extended family) Lack of preparation for parenting

Family dysfunction (eg, divorce, spouse abuse, chaotic family style)

Difficult child

Child neglect Emotional deprivation syndrome

Feeding disorders (eg, anorexia, bulimia)

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ORGANIC

Prenatal causes Prenatal causes Prematurity with complicationsPrematurity with complicationsMaternal malnutritionMaternal malnutrition

Toxic exposure in uteroToxic exposure in utero

Alcohol, smoking, medications, Alcohol, smoking, medications,

infectionsinfectionsIUGRIUGR

Chromosomal abnormalities Chromosomal abnormalities

Postnatal causes Postnatal causes Inadequate intakeInadequate intake

Poor absorption and/or use of Poor absorption and/or use of nutrients nutrients

Increased metabolic demand Increased metabolic demand

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COMBINATION

Chronic illness + social pressure

children with asthma, heart disease,

and CP all have or ganic reasons for

failure to thrive. In addition, the social pressures

(parental dysf unction, medications,

poor compliance) that children with

these conditions experience can cause behavioral changes that

result in decreased ener gy intake

and, therefore, failure to thrive.

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HISTORY

P

renatal history Smoking Alcohol consumption Use of medications Any illness during the pregnancy

Dietary history

how formula is prepared frequency of feeds, number of wet diapers and stools each day, and

a history of sequential weights type of food, meal frequency, and volume per feeding

Past medical history

illnesses that occurred since the neonatal period and signs of chronic conditions

Family and social history should include other siblings, living conditions, stressors, and data on parents' growth history

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PHYSICAL EXAMINATION Vital signs are usually within the reference range

Plot the head circumference, height, and weight on a growth chart

Growth charts should be evaluated for the pattern of failure to thrive

Edema Wasting

Hepatomegaly

Rash or skin changes

Hair color and texture changes

Mental status changes

Signs of vitamin deficiency

Irritability

Avoiding eye contact

Excessive sleepiness

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Failure of growth in weight, length, and head

circumference starting at birth, suggesting an

or ganic etiology that occurred in utero

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Growth failure in length and weight with a normal head

circumference in an infant with growth hormone deficiency.

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Constitutional delay of growth

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FTT secondary to caloric deprivation

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DIFFERENTIAL DIAGNOSIS

Child Abuse & Neglect: Failure to Thrive

Constitutional Growth Delay

Eating Disorder : Anorexia

Eating Disorder : Bulimia Fetal Alcohol Syndrome

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INVESTIGATIONS

CBC count

Urinalysis

Urine culture

Electrolytes, including

creatinine and BUN Liver f unction tests,

including total protein and albumin

Prealbumin may be used as a nutritional

mar ker Ser um insulinlike

growth factor I (IGF-I)

Insulinlike growth factor binding protein (IGF-BP3)

Human immunodeficiency vir us (HIV) testing

Sweat chloride test

T

hyroid f unction tests Stool studies for parasites or malabsorption

Immunoglobulins

Purified protein

derivative (PPD) skin test

Radiological studies

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TRE ATMENT

OUTP ATIENT INP ATIENT

DIAGNOSTIC THERAPEUTIC

Obser vation of Feeding

Parental-child interaction

Dietary habits

Perform tests & consults

Dehydration

Anemia

Infection

Electrolyte imbalance

Specific therapy

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DIET

Long-term goal for every child with failure to thrive is to provide adequate ener gy intake for growth!!!

Infants may be given concentrated formulas, assumingrenal f unction is normal

In toddlers, supplemental high-ener gy formulas as much as 30 kcal/oz are used.

Supplements for older children may include addingcheese, sour cream, butter, mar garine, or peanut butter to meals.

High-ener gy (approximately 1 kcal/mL) shakes

Multivitamin and mineral supplements, including iron and zinc, usually are recommended to all undernourished children.

In children with or ganic failure to thrive, continuous nighttime tube feeding also may be used to increase their ener gy intake.

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21

PROTEIN ENERGYPROTEIN ENERGY

MALNUTRITIONMALNUTRITION



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Definition of Malnutrition

The cellular imbalance between the

supply of nutrients and ener gy andthe body's demand for them to

ensure growth, maintenance, and

specific f unctions. (WHO)



Protein: deficit in amino acids needed for cell str ucture, f unction

Ener gy: calories (or joules) derived from macronutrients: protein, carbohydrate and fat

Micronutrients: vitamin A, B-complex, iron, zinc, calcium, others

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EPIDEMIOLOGY

In 2000, WHO estimated that malnourished children numbered 181.9 million (32%) in developing countries.

Estimated 149.6 million children younger than 5 years are malnourished when measured in terms of weight

for age. South Central Asia and eastern Africa, about half the

children have growth retardation due to protein-ener gy malnutrition.

Approximately 50% of the 10 million deaths each year

in developing countries occur because of malnutrition

in children younger than 5 years. In kwashior kor,

mortality tends to decrease as the age of onset

increases.

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PEM

PRIMARY

ACUTE

ST ARV ATION

CHRONIC

MARASMUS

KWASHIORKOR

MARASMIC-KWASHIORKOR

SECONDARY

GI DisordersWasting

disordersMetabolic demands

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Marasmus

Severely wasted (emaciated) & stunted

³Old Man´face, wrinkled

appearance, sparse hair,

baggy pants appearance.

No edema, fatty liver, skin changes

Too little breast milk or

complementary foods

< 2 yrs of age



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Kwashiorkor

EdemaMental changes

Hair changes

Fatty liver

Flaky paint Dermatosis/ Mosaic skin

Infection

High case fatality

Low prevalence

1 to 3 yrs of life



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Marasmic-Kwashior kor

edema occurring in children

who are other wise marasmic

and who may or may not have

other signs of kwashior kor.



HISTORY

In children, the findings of poor weight gain or weight loss; slowing of linear growth; and behavioral changes, such as irritability, apathy, decreased social responsiveness, anxiety, and attention deficit may indicate PEM. In particular, the child is apathetic when undisturbed but irritable when picked up.

Kwashior kor characteristically affects children who are being weaned. Signs include diarrhea and psychomotor changes.

Patients with PEM can also present with non-healing

wounds. This may signify a catabolic process that requires nutritional inter vention.

Detailed dietary history, growth measurements, BMI are essential

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PHYSICAL EX AMINATION

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31



IN

VESTIGATION

S Blood glucose

Examination of blood smears by microscopy or direct detection testing

Hemoglobin Urine examination and culture

Stool examination by microscopy for ova and parasites

Ser um albumin HIV test

Electrolytes

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...significant findings

hypoalbuminemia (10-25 g/L)

hypoproteinemia (transferrin, essential amino acids, lipoprotein)

Hypoglycemia

Plasma cortisol and growth hormone levels are high, but insulin secretion and insulinlike growth factor levels are decreased.

The percentage of body water and extracellular water is increased.

Electrolytes, especially potassium and magnesium, are depleted. Levels of some enzymes (including lactase) are decreased

circulating lipid levels (especially

cholesterol) are low. Ketonuria and a decrease in the

urinary excretion of urea because of decreased protein intake.

In both kwashior kor and marasmus, iron deficiency anemia and metabolic acidosis are present.

Urinary excretion of hydroxyproline is diminished, reflecting impaired growth and

wound healing. Increased urinary 3-methylhistidine is a reflection of muscle breakdown and can be seen in marasmus.

Malnutrition also causes immunosuppression, which may result in false-negative tuberculin skin test results and the subsequent failure to accurately assess for tuberculosis.

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TREATMENT

First step in the treatment of PEM is to correct fluid and electrolyte abnormalities and to treat any infections (hypokalemia, hypocalcemia, hypophosphatemia, and hypomagnesemia).

Second step (which may be delayed 24-48 h in children) is to supply macronutrients by dietary therapy. Milk-based formulas are the treatment of choice. At the beginning of dietary treatment,

patients should be fed ad libitum. After 1 week, intake rates should approach 175 kcal/kg and 4g/kg of protein for children. A daily multivitamin should also be added.

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Treatment of Severe PEM

Nutritious feeds: Breast milk;

Liquid feeds of skimmed milk, oil, sugar; soft

Cereal gr uels with milk, oil, sugar soft

Soft ripe fr uit, cooked vegetables

Establish a daily, graduated intake of - ~3-4 g protein per kg (actual) body wt

~200 kcal of ener gy per kg body wt

V Reddy, Protein Ener gy Malnutrition. Diseases of Children in the Subtropics & Tropics, 4thed Ed P Stanfield et al, London:Hodder & Stoughton, 1991

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Treatment of Severe PEM

(cont¶d)

More frequent small feeds better than lar ge meals

Micronutrient supplements: To treat clinical conditions (eg, anemia,

xerophthalmia)

To prevent f urther deficiencies

Water for thirst

Treat infections and illnesses; eg, Diarrhea: ORS & zinc

Antibiotics, as indicated

Prevent hypothermia36



PROGNOSIS

Some children develop chronic malabsorption and pancreatic insufficiency. In very young children, mild mental retardation may develop and persist until at

least school age. P

ermanent cognitive impairment may occur, depending on the duration, severity, and age at onset of PEM.

The extent of growth failure and the severity of hypoproteinemia, hypoalbuminemia, and

electrolyte imbalances are predictors of a poorer prognosis.

Underlying HIV infection is associated with a poor prognosis.

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THANK YOU !

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FTT and PEM

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