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Failure to thrive

This is a video on failure to thrive, including how it's defined, assessed, as well as causes of failure to thrive. This video was made using Google Slides. All images were created or adapted from Wikipedia Commons. ADDITIONAL TAGS: FAILURE TO THRIVE Definition: Pediatric patient with failure to gain weight or inappropriate loss of weight. Pathophysiology Nutritional intake does not support normal growth and development. This can be because of inadequate calorie intake; malabsorption (calories are going into the gut but not making it into the blood/body); and/or increased metabolic demand Diagnose Plot growth curves for height, weight, head circumference Drop off of growth curve (falling below =2 centile spaces [parallel lines]) and wt for age (or wt for ht) below 3rd %ile are concerning In FTT, weight drops first, then height, then head Weight loss is normal after birth, but babies should lose =10% of their birth weight and regain within 3 weeks Interview. Ask about: Feeds: How frequent? How much? How do they mix formulas? Stools: How frequent? How much? Consistency, color... Rule out abuse. Look out for: Suspicious wounds, bruises (in various locations, diff stages of healing, not consistent with story) Circular burns (cigarette), water dunk burns (feet, ankles, butt only) Running from caregiver, fear of caregiver Differential diagnosis (next) Inadequate caloric intake Inadequate food supply: #1 etiology globally; caused by poverty or poor understanding of feeding; insufficient food supply from bottle or breast Postpartum depression/maternal depression: mothers with postpartum depression are at increased risk for experiencing breastfeeding difficulties Child neglect: #1 cause in USA (5-10%); Cleft lip and cleft palate: uni- or bilateral; hard and/or soft palate; apparent on exam; impaired oral motor coordination → poor suck and poor swallow; repair lips at 10-12 weeks, palate 10-12 months, or risk speech/feeding/hearing problems and otitis media Gastroesophageal reflux disease: sx- irritability, fussiness, and spitting up after feeds; pathophys is short esophagus, partial LES closure, lying supine; tx- smaller feeds, tummy time after meals; resolves by 1-2 yo Malrotation: (of intestines during development); dx- x-ray, u/s might show GI tract cutoff; predispose to volvulus (gut twisting around mesenteric blood supply) → n/v, abd pain, distension, large dilated loop on x-ray; tx-corrective surgery Pyloric stenosis: usually boys, 2-8 wks; forceful, projectile vomiting immediately after feeds; ex- olive-shaped mass, peristaltic waves; dx- low K, low Cl, metabolic alkalosis, donut sign on u/s; tx- IV fluids and surgery Cerebral palsy/hypotonia Avoidant/restrictive food intake disorder (ARFID) Malabsorption/caloric retention defect Food protein induced proctocolitis: non-IgE mediated allergy, 2-3%; sx: fussy after feeds, vomiting, bloody stool with cow’s milk (+/- soy); switch to hydrolyzed formula; try again at 2-3 yo Celiac disease Short bowel syndrome: necrotizing enterocolitis is the most common cause. Cystic fibrosis: AR mutation of CFTR; meconium ileus (FTPM); dx: newborn screen, or salty taste → sweat Cl test ( 40 infants, 60 peds); malnourished → supplement pancreatic digestive enzymes and DEAK vitamins; repeated resp infxns (pulm toilet, tx pseudomonas); infertility in men; kyphoscoliosis; digital clubbing Biliary atresia: sx- FTT + jaundice, acholic stools; dx-high direct bili, u/s showing no ducts; tx- surgery to salvage liver (Kasai procedure) Increased metabolic demand Hyperthyroidism: FTT + bulging eyes, tachycardia, irritability vs Hypothyroid: constipation, poor feeding (not eager) Chronic infections: tuberculosis, HIV, CVID, SCID TORCH infections: congenital infxns that cause FTT + HSM, anemia, jaundice, chorioretinitis, purpura; Toxoplasmosis- parasite from cat poop, raw meat, soil → brain Ca, hearing/vision loss, seizures; Other (syphilis) →palms/soles rash, saber shins, saddle nose, Hutchinson’s teeth, dx-VDRL, RPR, then dark field or FTA ABS; tx-penicillin Rubella → purpura- ‘blueberry muffin’ baby; cataracts; deafness; heart defects; tx-supportive Cytomegalovirus → periventricular Ca; dx-urine, saliva → viral titers, PCR Herpes → painful, burning vesicles on erythematous base (dew drops on rose petal); dx- PCR; tx- acyclovir Inflammatory bowel disease: ulcerative colitis vs Crohn’s Diabetes mellitus (FTT + polyuria, polyphagia, polydipsia) Congenital heart defects: pansystolic murmur → echo → VSD → right hypertrophy (Eisenmenger syndrome); sx: enlarged liver, respiratory distress Chronic lung disease: bronchopulmonary dysplasia, bronchiectasis Inborn errors of metabolism: galactosemia (FTT+bilateral cataracts, jaundice), glycogen storage diseases (FTT+HSM, cirrhosis)