SUS

ByWilliam Bithoney

Patrick CaseyRobert Karp

FAILURE TO THRIVE

SUS

SUS

Failure to Thrive

Abnormal weight status during infant-toddler years

and/or

Abnormal weight gain (weight growth velocity)

SUS

Abnormal weight status Referenced against:

• Genetic growth expectations for family• Children of same gender and gestation

adjusted age – <5% on NCHS curves

• Child's own length – <10-25% on NCHS curves

SUS

Abnormal weight gain (Growth Velocity)

• Falling across two standard deviation percentile lines on NCHS curves over 6 month period

• For at least one to two months

SUS

FTT Definition includes:

"light""thin"

atypical weight gain

SUS

Cautions Regarding Definition of Failure-to-Thrive

• Genetically small due to parents size • Children born small for gestational

age (SGA) may never catch up• If born larger than long-term genetic

potential demonstrate decreased growth rate in first 2 years

SUS

FTT Definition: Growth Only

• Not necessarily associated with developmental/emotional problems in child

• Not necessarily environmental causation

SUS

What's in a name?

Growth DelayGrowth FailureFailure to Grow

Growth DeficiencyFailure to Gain Weight

SUS

FTT of long duration (Grown Older)

STUNTED:• Abnormal length and head

circumference• Psychosocial Dwarf?

SUS

Failure-to -thrive Cause:

All children with Failure-To Thrive

are Undernourished

SUS

Three Methods to Categorize Undernutrition in Children

Degree of Under-Nutrition

NoneMildModerateSevere

Gomez:% medianweight-for age

>9075-9060-74<60

Waterlow:% medianweight-for-height

>9080-9070-79<70

McLaren,Read:% median wt/htfor age ratios

>9085-9075-84<75

SUS

Categorization of Undernutrition in 258 Children Referred for "Failure to Thrive"

Degree of Under-Nutrition

NoneMildModerateSevere

Gomez

No.

51321129

%

251434

Waterlow

No.

64149423

%

2558161

McLaren,Read

No.

183815646

%

7156018

SUS

Clinical Subtypes

I. Medical Cause– Organic vs. Non-organic vs. Mixed

II. Clinical Presentation – Age of onset– Severity– Chronicity

SUS

• Organic Etiology:– medical disease present and clinically judged to be sole

cause of FTT

• Non-organic Etiology:– problems in the child's environment judged to be the

primary cause of FTT, in the presense or absence of medical disease

• MIXED Etiology:– medical problem and problems in environment in

combination are judged to be cause of FTT

SUS

Problems with Organic/Non-Organic Dichotomy

1. It is often difficult to place a child in either category

2. The dichotomy fails to account for the compounding effect of problems in both the child and the environment

SUS

Problems with Organic/Non-Organic Dichotomy (Cont'd)

• 3. Children with either may have symptoms like diarrhea or vomiting

• 4. Children with either may gain weight while in the hospital

• 5. Global terminology is not specific enough to develop an individualized management plan

SUS

Clinical Subtypes (Cont'd)

III. Socioemotional

0-3 months

4-10 months

11-36 months

Homeostasis

Attachment disorder

Separation individuation disorder

SUS

Clinical Subtypes (Cont'd)

IV. Psychiatric DiagnosesFeeding DisorderDepressionReactive Attachment Disorder

V. Mechanical Feeding DisorderFood Avesion

SUS

Transactional FTT

Multiple aspects (overt or subtle) of child, parents, and the proximal and distal environments interact across time to result in FTT.

SUS

Final Diagnosis of 131 Cases of Failure to Thrive

Non-organic

Interactional

Organic

Unknown

Number59

46

22

4

Percent45

35

16.7

3.3

SUS

Frequency of Organic Systems Causing Failure to Thrive

GastrointestinalNeurologicalRespiratory-PulmonaryCardiovascularEndocrineOther

Most Common

Least Common

SUS

Prevalence of Failure to Thrive

• 3.5% of admissions to children's hospitals

• 10% of clinic visists in urban and rural outpatient settings

• up to 16% 0-4 year olds in low income populations are "stunted"

SUS

Failure to Thrive

• Weight is abnormally 2 standard deviations below the mean for gestation corrected age -- and/or

• weight crossess percentile curves by two standard deviations

• weight to height ratio is depressed

SUS

"My baby is just small for her age"

-Parent

SUS

Failure to Thrive: Spectrum of Causes

Problem in the Child

ORGANIC

Problem in theEnvironment

NON-ORGANIC

Interactive

Effects

SUS

Parent Functioning

Child Outcomes•Development•Learning•Behavior•Growth•Health

SUS

Goals of Clinical EvaluationIdentify conditions which:1. Negatively affect growth potential (disease)2. Increase basic caloric needs (e.g. chronic

infection)3. Decrease availability/utilization of calories

(e.g., malabsorption)4. Negatively affect parents ability to meet

nutritional needs (can't/won't eat)

SUS

Diagnostic Evaluation

1. Growth assessment – confirm the diagnosis with weight and

height, present and past

2. History– predisposing factors

3. Physical examination– significant findings other than

malnutrition

SUS

Diagnostic Evaluation (Cont'd)

• 4. Development-Behavioral Assessment– Assess delays in cognitive, language, or

motor functioning– Identify any behavioral abnormalities

• 5. Laboratory Evaluation– Varies for each child– Stepwise approach is recommended

SUS

Laboratory Evaluation

• Should be directed by findings from the history and physical examination

• Document nutritional status:– albumin, iron, zinc

• Child may have endemic problem: – Tbc, AIDS, giardia

SUS

Diagnostic Evaluation (Cont'd)

• 6. Nutritional and Feeding Evaluation– Content and structure of mealtimes – Feeding techniques

• 7. Social History– Identify parental/family strengths and

weaknesses

SUS

• 8. Parent/Child Interaction– Especially as it relates to feeding

• 9. Psychiatric Evaluation– Important if the caregivers emotional

state is adversely affecting parent-child interaction

Diagnostic Evaluation (Cont'd)

SUS

Hospitalization vs. Outpatient Care

• Advantages of hospitalization:– Able to observe and control feeding– Able to observe the parent-child interaction– Medical evaluation can be done easily

• Disadvantages of hospitalization:– Cost– Child (and parent) are away from their

normal environment

SUS

Indications for Hospitalization of Children with Failure-to-Thrive

1. Evidence of physical abuse2. Extreme failure to thrive (starvation)3. Extremely dysfunctional parent-child

relationship or family4. When distance and transportation issues

mean outpatient management is not practical

5. When outpatient management has failed

SUS

Management of the Child with Failure-to-Thrive

1. Nutritional asessment and intervention2. Improved parent-child interaction3. Developmental stimulation4. Treatment/management of medical

conditions5. Support and intervention for social and

family problems6. Mental health referrals where indicated7. Regular follow-up care

SUS

Best Predictors of Prognosis

• Age of onset, chronicity• Ongoing quality of the home

environment

SUS

Interactional Model of Failure-to-Thrive

PARENT•Economic Status•Health•Knowledge•Emotional State•Past Experience

CHILD•Appearance•Health•Neuro developmental maturity•Ease of Caregiving

Parent-Child Interaction

Failure-to-Thrive

Endocrine-CellularDysfunction

Nutritional Deficiency

SUS

Environmental Characteristics: Supports and Stressors

• Home– -Marital Relationship– -Physical Quality– -Organization– -Stability– -Economic Resources

• Family• Neighborhood and Work