Failure to thrive, FTT

Notes

## Basic introductiona,b,c,f

  • FTT is said to occur when a child’s physical growth is much below what is expected for the age

OR

  • FTT is said to occur when weight for height of a child is more than 2 Standard Deviations (2SDs) below the mean for age and sex

    OR

  • FTT is said to occur in a child when the weight curve has crossed downward more than 2 major percentiles

OR

  • FTT is the lack of attainment or maintenance of the growth potential expected for a child

OR

  • FTT is said to occur when growth falters to below the 5th or 3rd centile for age
  • It is a symptom rather than a disease or diagnosis
  • Some authorities prefer the use of the term “Growth faltering” rather than FTT
  • “Growth faltering” is defined as a reduction in the expected rate of growth along an infant’s previously defined growth curveb

## Normal growth

  • Infants are expected to regain their birth weight by 2wks with a growth rate of 15-30g per day
  • Length increases by 25cm in 1st year
  • Head circumference is about 35cm at birth to about 47cm at 1 year

## Major Anthropologic Categories of FTT

  • Type I category have lower weight, lower OR higher height and normal head circumference and it is manifested in malnutrition of organic or non-organic etiology
  • Type II category have lower weight, lower height and normal head circumference and it is manifested in endocrine disorders, bone dystrophy and constitutional short stature
  • Type III category have lower weight, lower height and lower head circumference and it is manifested in chromosomal disorders, metabolic disorders, and severe malnutrition

## Causes of FTT (enlisted based on disease or disease condition)

  • Causes for FTT can be classified as organic (infections, physiological and physical) or inorganic (psychosocial, without underlying medical condition)
  • Psychosocial Nutritional

_Kwashiorkor

_Marasmus

_Zinc/iron deficiency

_Vitamin D deficiency

_Hypophosphatemia

  • Feeding disorders

_Cleft palate

_Dentitions

_Oral-motor apraxia            

  • Gastrointestinal disorders

_Celiac disease

_Central nervous system lesion

_Chronic toddler diarrhea

_Diarrhea

_GERD

_Inflammatory bowel disease (IBS)

_Malabsorption

_Structural anomalies

_Vomiting

  • Hepatic disorders

_Chronic hepatitis

_Glycogen storage disease   

  • Infectious diseases

_HIV

_Tuberculosis

  • Endocrine disorders

_Central nervous system lesions

_Growth hormone deficiency/resistance

_Hypercortisolism

_Hypothyroidism

_Pituitary insufficiency

_Pseudohypoparathyroidism               

_Type I diabetes mellitus     

_Vitamin D resistance

  • Cardiac disorders
  • Pulmonary disorders
  • Renal disorders
  • Central nervous system disorders
  • Cancers
  • Other diseases

## Causes of FTT (based on Prenatal and Postnatal causes)

  • Prenatal causes include: prematurity, intrauterine growth restriction, and exposure in utero to toxic agents
  • Postnatal include inadequate intake of calories in food, increased demand of calories, poor absorption of caloric food, and defective utilization of calories
  • Inadequate caloric intake can be due to:

_Poverty

_Incorrect preparation of infant formula

_Feeding challenges due to body deformities

_Child neglect / abuse

_Education level of infants' mothers

_Poor feeding habits

_Post natal maternal depression

_Domestic Violence

_Unwanted child

  • Poor absorption of caloric food can be due to:

_Biliary Atresia

_Celiac disease

_Cystic fibrosis

_Milk allergy

_Necrotizing enterocolitis

_Vitamin deficiency

  • Increased metabolism

_Hyperthyroidism

## Statistics

  • The global prevalence of FTT is 1-5%
  • When the weight, height and head circumference are all below the expected parameters for the age, the incidence of organic disease is about 70%

## Consequences of FTTd

  • Delayed cognitive and psychomotor development
  • Increased risk of death
  • Reduced immunological response
  • Reduced learning ability
  • Reduced physical activity.
  • Stunted growth
  • Increased susceptibility to infections
  • Re-feeding syndrome (abnormalities in fluid balance, glucose metabolism, vitamin deficiency, hypomagnesaemia, hypophosphatemia and hypokalemia)
Symptoms
  • Stunted growth
  • Unkempt child
  • Delayed psycho motor and speech development
  • Poor child-parent interaction
  • Other diseases as mentioned above
Diagnosis
  • Clinical review including physical examination and history
  • The 3 parameters of weight, height and head circumference are monitored
  • Accurately plotting and evaluating growth charts at every visit
  • For children below 2yrs, recumbent (lying down) length is commonly used rather than standing length
  • Sometimes, laboratory tests such as:

_FBC

_ESR

_CRP

_Glucose test

_Thyroid function tests

_Urinalysis

_Stool for Ova and Cyst

_HIV 

_TB

_CXR

Differential
  • Underlying diseases in FTT
Prevention
  • Proper feeding of the child
  • Promotion of exclusive breast feeding for early infancy
  • Community efforts
  • Satisfactory antenatal care
  • Early detection and treatment of FTT
  • Screening of neonates for treatable metabolic disorders
Reference

a. McDowell, M. A., Fryar, C. D., Ogden, C. L., & Flegal, K. M. (2008). Anthropometric reference data for children and adults: United States, 2003–2006. National health statistics reports, 10(1-45), 5.

b. McDonald, E. L., Bailie, R. S., Rumbold, A. R., Morris, P. S., & Paterson, B. A. (2008). Preventing growth faltering among Australian Indigenous children: implications for policy and practice. Medical Journal of Australia, 188(8), S84.

c. De Onis, M., Wijnhoven, T. M., & Onyango, A. W. (2004). Worldwide practices in child growth monitoring. The Journal of pediatrics, 144(4), 461-465.

d. Black, R. E., Allen, L. H., Bhutta, Z. A., Caulfield, L. E., De Onis, M., Ezzati, M., ... & Maternal and Child Undernutrition Study Group. (2008). Maternal and child undernutrition: global and regional exposures and health consequences. The lancet, 371(9608), 243-260.

e. Onyiriuka, A. N. (2011). Evaluation and Management of the Child with Failure to Thrive. Hospital Chronicles, 6(1), 9.

f. Kenyan Ministry of Health. Clinical guidelines for management and referral of common conditions at levels 4-6. Hospitals. 2009; 3:259-261.http://apps.who.int/medicinedocs/documents/s21000en/s21000en.pdf

Management
  • Nutrition intervention such as high-calorie diet and close follow-up
  • If the weight is less than 60-70% of ideal weight or the child has hypothermia, bradycardia or hypotension, admit to manage in hospital
  • Management of the underlying disease(s) such as gluten free diet in cases of celiac disease, diabetes among others
  • Counselling of the mother (very useful in case of non-organic FTT)
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