Failure to thrive - Rural Health West

MATERNAL SECURITY – A Sculpture in Front Lobby of PMH for Children in Perth WA
“Youth of Today - The elders of tomorrow”
Failure to thrive: up-to-date guidelines on
assessment, treatment and management of
Infants and children
Growth
Development
Aboriginal Health Conference 2016
RURAL HEALTH WEST
Hotel Pan Pacific Rural Perth WA
GROWTH AND DEVELOPMENT
IN CHILDHOOD
Arvind Sharma
General Paediatrician
Rockingham General Hospital
South Metropolitan Health Service
Department of Health, Western Australia;
Adjt Clinical Senior Lecturer
School of Paediatrics and Child Health,
University of Western Australia;
Ex-Regional Consultant Paediatrician
Kimberley, WACHS, WA And
Adjt Associate Professor
School of Medicine Fremantle
University of Notre Dame Australia
GROWTH (PHYSICAL INCREASE IN SIZE) - 1
GAUSSIABN CURVE
(Normal population distribution is a symmetrical and bell shaped curve)
Z Scores ( -1SD to + 3SD) 60% within +/- 1SD /95% within +/- 1.96SD of
mean and 2.5% outside the range or two tails or +/- 3 SD around the mean
NORMAL MALE Populations
NORMAL FEMALE Populations
NORMAL GROWTH CHARTS (From various populations around the world)
SPECIAL GROWTH CHARTS
(For special populations - Down/Turner/William/Noonan/Achondroplasia)
Factors influencing growth
Genetics (Familial and Racial)
Hormones
Non pathological factors – Mainly Nutrition,
Psychosocial influences , Physical activity , Play
All these has an important roles on growth and development
Different factors become dominant at varying stages of childhood
growth: In-utero environment in foetal growth; Nutrition in first
year of life; Growth hormones during childhood and sex
steroids at puberty .
GH is the principal hormone in somatic growth and
body composition. Other hormones like thyroid
hormone, adrenal androgens and sex steroids contribute
to growth via their interaction with GH-IGF-1 axis
ANTROPOMETRY
WEIGHT (Wt)
LENGTH (Lth)/HEIGHT (Ht)
HEAD CIRCUMFERENCE : Occipito-Frontal (HC)
HC grows 2cm/month for first 3 months then
1/2cm per month until 1year and then 10cm
total from 1 year to adult life
Posterior Fontanelle closes by 8 weeks
Anterior Fontanelle closes by 12 to 18 months
GROWTH: Centiles/Percentiles (P)
Normal population based studies with analysis of data
PERCENT oF NORMAL (%)
PERCENTILE (Grouped population data )
MAJOR CENTILES : 2-3-5-10-25-50-75-90-95-97-98
CORRECTED WEIGHT FOR HEIGHT/LENGTH/HC FOR AGE
(Corrected to 40 weeks of GA FOR ALL PREMMIES)
Upper and Lower Segment Measurement useful
Arm Span Measurement also useful (Height concerns)
CORRECTION OF MILESTONES For GA is Also USEFUL
GROWTH PARAMETERS
PEM CLASSIFICATIONS
NORMAL >80% (Wt for Age or Wt for Ht)
Under Wt < 70% (Wt for Age or Wt for Ht)
MARASMUS 60% of expected weight for age
KWASHIORKOR (Weight loss with oedema and other specific features)
MK-Mixed presentations
BMI (Wt and Ht derivative)
BSA (Wt and Ht Derivative))
TYPES OF GROWTH with age
Foetus/Newborn/INFANT/Toddler/Preschool child/
School going child/PUBERTY/ADOLESCENCE/Adult
PUBERTY STAGES I-V ( Ht Spurt - F 12yr : M 14yr)
↑ periods of GR in infancy , early childhood and adolescence
↓ periods of GR in middle childhood period
Each child grows in his or her own unique way
Useful Measurements -1
CHEST CIRCUFERENCE
(HC=Chest Circumference by 1yr of age)
ABDOMINAL GIRTH
WAIST CIRCUMFERENCE
MID ARM CIRCUFERENCE
TRICEPS SKIN FOLD THICKNESS
SUBCUTANEOUS FAT ASSESSMENT (ARMS/BUTTOCKS)
MUSCLE MASS ASSESSMENT (ARMS/LEGS)
USEFUL MEASUREMENTS -2
BMI kg/m2 (Wt and Ht derivative) Wt in kg/Ht m2
Bodyweight in kilograms divided by height in meters
squared.
BMI Centiles are available on some Growth charts: 5-50-90
BMI Categories kg/m2:
Underweight = <18.5
Normal weight = 18.5–24.9
Overweight = 25–29.9
Obesity (Class I- III) = BMI of 30 or greater
BSA (m2)( Wt and Ht Derivative)
BSA (m2) = SQRT( [Height(cm) x Weight(kg) ]/ 3600 )
Growth Types and Growth Periods
FOETAL ( FASTEST)
Newborn (FASTER)
INFANT (TODDLER) (Fast)
Pre School Child (Slow)
School Going Child (Slow)
PUBERTY (Growth Spurt - FAST)
ADOLESCENCE (MALE/FEMALE) (Faster)
ADULT (MALE/FEMALE) (Slowest)
NORMAL GROWTH 0-5year (WHO)
BODY PROPORTIONS WITH AGE (Nelson’s Textbook of Paediatrics)
Expected weight gains (weekly weighing)
• 0-3/12
• 3-6/12
• 6-12/12
• >12/12
150-200gm/week
(20-30gm/day)
100-150gm/week
(15-20gm/day)
70-90gm/week
50-70gm/week
(Naked weight taken before feeding )
Official Department of Health Growth Chart (WA)
Purple book record for a male child referred for FTT
3 year old Sri Lankan boy referred for FTT from his GP
Weight gain (Growth) with age
Birth : 3.25kg (Average birth weight in WA)
• 6/12 : 6.5kg (Double)
• 12/12 : 10.75kg (Triple)
• 5yr : 20kg
• 10yr: 30kg (10 times)
• 15yr: 45-55kg
• Daily weight gains
• 20-30gm/day First 4 months
• 15-20gm/day from 5 to 12 months
• 2.5kg/year – 2nd year onwards until puberty
Length and Height Growth Rates
Birth 50 cm
1 year 75cm (One and half time)
4 year 100cm (Double)
4yr to just before puberty 5-8cm/year
Pubertal growth spurt
Girls 12 year
Boys 14 year
Head Circumference growth rates
Birth : 35cm
3 month : 41cm
(First 3 months 2cm/month)
1 year of age 50cm (one and half time)
(4-12 months 1cm/month)
1year to adulthood 10cm total increase in size
• Adults: 56-62cm Males
• Adults: 54-60cm Females
Growth record 61/2 month old girl who was referred for posterior flat head/plagiocephaly from her GP
DEVELOPMENT
• Development refers to a progressive increase in skills
and capacity of functional achievements
• It is a qualitative change in child’s functioning
• It can only be measured through close observation
It requires close surveillance until age 17 years
by Parents/CCHN/GP/General Paediatrician
It follows cephalo -caudal progression (Head to Toe)
It also follows Proximodistal progression
(Center of body to periphery)
DEVELOPMENT DOMAINS
Motor development
Gross Motor
Fine Motor (Hand Eye Coordination-Vision)
Cognitive
Hearing and Language
Emotional : Crying, Social smile, laughter, anger,
fear, sadness, pleasure, jealousy, anxiety, affection.
Social : Smile/Stranger anxiety/Response to name/
play/imitation/sharing/taking turns/part of a group
Factors affecting growth and development
• HEREDITARY/FAMILIAL
• ENVIRONMENTAL
PRENATAL
NATAL
POSTNATAL
Neurological Status
NUTRITION
PSYCHOSOCIAL
EMOTIONAL/PLAY
• CHRONIC ILLNESS
• ACUTE ILLNESS
• HORMONES
Failure to Thrive (FTT)
An up-to-date Assessment,
Treatment and Management
in Infants and Children
WEIGHT FALTERING
GROWTH FALTERING
CURRENT THINKING
Definition - ICD 10 (version 2016)
R 62.8 OTHER
LACK OF EXPECTED NORMAL PHYSIOLOGICAL DEVELOPMENT
FAILURE TO:
GAIN WEIGHT
THRIVE
INFANTILISM
LACK OF GROWTH
PHYSICAL RETARDATION
(EXCLUDING HIV RELATED AND PHYSICAL RETARDATION DUE TO
PROTEIN ENERGY MALNUTRITION OR SEVERE UNDER NUTRITION)
R 62.9 UNSPECIFIED
LACK OF EXPECTED NORMAL PHYSIOLOGICAL DEVELOPMENT
Chronology of Failure to Thrive (FTT)
Failure to Thrive (FTT) was first used by Holt in 1897
and it was first published in a dictionary in 1933
Failure to gain weight with poor emotional and
developmental progress is its hall mark
Undernutrition (Commonly used term)
Poor Growth (low Wt and Ht centiles - less popular)
The terms below are less emotive and more accurate
Weight Faltering (New)
Growth Faltering (New)
Anthropometric Criteria (Old School)
PEM Classification
• Weight <75% of median weight for age (GOMEZ)(USA)
. Weight <70% for age (UK)
• Weight <80% of median weight for length /age (WATERLOW)(WHO)
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BMI for age <5th centile
Weight for age <5th centile
Length for age <5th centile
Low conditional weight gain or regression from mean Wt for age
Growth Foundation Criteria Country specific (General)
• Weight deceleration when crossing >2 major centiles using
• 3,5, 10, 25, 50, 75, 90 and 95 centile lines in any age group
Ref: Adapted with permission from Olsen EM et al, 2007.2
Weight faltering
• Under Nutrition (weight <70% some studies<80%)
• Poor Weight gain (low weight gain over time)
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Under weight (low weight for age)
Weight below 2nd -3rd or 5th centile
Weight loss crossing 2 major centiles
Low weight for length or low weight for height
• Poor weight gain for age (Commonly used)
Anthropometric Criteria (USA) (Ref: J of AFP 2011)
Body mass index for age less than the 5th percentile
Length for age less than the 5th percentile
Weight deceleration crossing two major percentile lines
Weight for age less than the 5th percentile
Weight less than 75% of the median weight for age
Weight less than 75% of median weight for length
Weight velocity less than the 5th percentile
I AM NORMAL DOCTOR
from Penguin Island Perth
Prevalence
(Based on criteria and growth chart used to plot growth figures)
• 1 in 10 in primary care (USA) < 2year olds
Higher in suburban , LIG and rural populations
• 20-40% all age groups (Developing world)
(under weight seen as Wt < 80% of weight for age)
• 1 in 100 (1%) in older children (Developed world)
This depends on definition used and demographics
Higher rates are seen in economically disadvantaged
populations: Recent migrants, refugees, city slums and
urban and suburban LIG populations.
Birth Weight: Myth about future growth
Birth weight is not a guarantee for potential future weight
Growth after 4 /6 months of age depends on many factors
There is always an adjustment in growth trajectory by six
month of age
Some children are born small and catch up later
Others are born large and lose weight to reach their own
lower centiles / growth trajectory by 4 to 6 month of age.
WE ARE SMALL BUT NORMAL DOCTOR IT IS RACIAL
Growth Faltering
• Failure to gain weight at an adequate rate for age
• Commonly seen in infancy : < 2 years of age
This may occurs singly or in a combination of :
1. Failure of carer to provide adequate calories
2. Failure of child to take sufficient calories
3. Failure of child to retain adequate calories
Inadequate intake, excessive loss, increased metabolic
demand without extra intake and energy malabsorption
is seen in CD and CF which leads to an energy deficit state
with deficit of micronutrients (minerals and vitamins)
Calories or kCal = Energy or kJ
Children presenting to GP or CCHN for FTT
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Infants
Toddlers
Recent Immigrant
Refugee
Children from a dysfunctional family
Case referred from DCPFS (Foster care)
Small children by heritage/race (Familial)
Constitutionally small children
Ex-pre or IUGR children
Typical case
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Complex and brief history
Full anthropometric data not available
Normal Physical Examination
Poorly maintained health book
Multiple health care providers involved
Unclear diagnosis at primary care level
Multiple presentations to hospital/GP
Poor weight gain or poor progress over time
Oetiology not clear even at specialist level
History : 1
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5 month old Male Caucasian child
4 week history of poor feeding
Slow weight gain
Initially breastfed with no issues
Now little reluctant to take BF or Bottle Feeds
Attaches to Nipple well but only for 5minutes
Cries after every feed
Not pulling legs up/No S/S of abdominal pain
Mother has good breast milk supply
Personal hygiene good
Good home environment
History : 2
Having 4+wet and two dirty nappies daily
 No diarrhoea or vomiting
 Little posseting at times
 Stools normal
 Well settled between feeds
 Sleeping longer hours
 S/S of URTI noted, no skin rash or fever
 Elder sibling recovering from URTI
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 F/H of Coeliac Disease (CD) in maternal grandfather
but two of his sibs tested and found negative for CD.
History : 3
 Born at 36+4/40 to a PET, GDM O+ mother
Needed CPAP with 40% O2 for first 12 hrs
 Diagnosed with GORD at 4/52 of age
 Given Omeprazole 5mg BD X 4/52
 Also conservative measures for GORD
 Immunisations: up-to-date
 Development: Normal for age
 No H/O eczema or seborrhoea
 No H/O blood or mucus in stools
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Purple Book - Progress notes record
WEIGHT: (naked weight before feeding!)
Sept 3rd week Wt : 3.100kg (Birth Wt)
Jan 4th week Wt: 5.5kg
Feb 2nd week Wt: 5.24kg
Feb 3rd Week Wt: 5.26kg
Weight dropped from 10th to 3rd centile over
the past 6 weeks
Length: 50th percentile (One reading from GP)
HC: 97th percentile (One reading from GP)
Weight Growth Chart
Length Profile
Length Growth Chart ?
HEAD CIRCUMFERENCE GROWTH CHART ?
Physical Examination
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Thin looking happy and smiling child
Alert, well settled, good eye contact , afebrile and pink
Anterior and Post fontanelles : Palpable
Hydration ; Good
Facies : Normal
HEENT: NAD
Mouth: NAD
LN: NAD
Vitals: CRT<2sec/ HR130 Regular/ SpO2 98% RR30
CVS: NAD (no murmurs and all pulses present)
Chest: Normal shape
Lungs: Clear
Abdo: Soft, no organomegaly and no faecal loading
CNS: NAD
Differential Diagnosis
Group 1
1. GORD
2. Coeliac Disease
3. Cows Milk Protein Allergy/Intolerance
4. Eosinophilic Oesophagitis
5. Feeding problem (Minor Neurological issues)
6. Oro-motor dysfunction
(Sucking and Swallowing Incoordination)
7. Posterior tongue tie
8. Psychosocial issues
Group 2
1. Acute GI or Respiratory Infection(Recovering)
2. Poor weaning
3. Inborne Error of Metabolism (IEM)(Metabolic cause)
4. Renal Tubular Acidosis
5. Other cause – Neglect/NAI
Most likely Diagnosis
GORD
Feeding Problem
Neurological Issue
Psychosocial issue
Neglect
MANAGEMENT PLANS DISCUSSED
1. Refer to dietitian
2. Admit to ward
(For feeding and close observation)
3. Home with dietary advice and OPD review
4. Investigate and OPD review after a week
5. Inform SW and /or DCPFS
6. Refer to Speech Pathologist
7. Reassure (No action)
8. D/W sub-specialist ENT/Gastroenterologist
9. Refer to OT/Feeding team
Agreed plan : Admission For
Supervised feeding
Nursing Observation
Energy dense feeding
Start Supervised Weaning
Dietician Review
Assessment by feeding team
Lactation Specialist Consultation
Record weight gain
Observe parental interaction
Do some investigations
Formulate a structured management plan
Home with a safety net of GP/CCHN
INVESTIGATIONS
FBP/CRP/PCT/ESR/TFT/UEC/LFT/CPM/Iron Studies
CD screen
Urine Metabolic screen with GAG
Neonatal Screening report
Viral PCR
Urine MECS
Stool fat globules and crystals/viral PCR/MECS
Cranial USS
CXR/CT or MRI Head (not done)
Skeletal Survey (not done)
Barium Swallow (not done)
Gastric pH study (not done)
Plasma Zn/Cu/Lead (Not done)
Which test will be positive ?
FBP/CRP/PCT/ESR/TFT/UEC/LFT/Iron studies/CMP
CD screen
Urine Metabolic screen
Neonatal Screening report
Viral PCR
Urine MECS
Stool fat/viral PCR/MECS
Cranial USS
CXR/CT or MRI Head (not done)
Skeletal Survey (not done)
Barium Swallow (not done)
Gastric pH study (not done)
Plasma minerals Zn/Cu / Lead (not done)
ALL TESTS RESULTS REURNED
NORAML
What should be our next step ?
Reassessment
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Review of test reports
Review of nursing observation charts
Refer to MDT
Organise case conference
D/W Dietitian
Stay on the ward
Progress on the ward
Still Fussing during feeding
 Distressed after 4-5minutes of feeding
 Sleeping for long periods
 Weight loss 95gm over 2 days
 Supervised feeding continued
 Seen by dietitian twice
 Nursing reports non-specific
 Parents very nice and caring
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Investigations revisited
Basic bloods : Normal
 LFT : Normal
 Ferritin: Normal
 TFT: Normal
 Stool : Normal
 Urine : Normal
 Urine Metabolic Screen : Negative
 Coeliac Screen : Negative
 Cranial USS : Normal Study
 PNA for viral PCR : Negative
 Vitamin levels(B12/ Vit. D/Folate): Normal
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What is the most likely diagnosis ?
Group 1
 GORD
 Feeding Problem
 Poor Oromotor coordination
(Sucking Swallowing incoordination)
Group 2
 Cow’s Milk Protein Allergy or Intolerance
 Psychosocial (Environmental)
 Neglect/NAI
 Coercive feeding practice
 IEM
DISCHARGE PLANNING
On Day 2 of admission: weight loss persisting
95g lost since arrival to ward (no weight gain)
 Decision to trial on solids (Weaning )
 Dietician review – fortify breast milk, increase
concentration of formula (calorie dense milk)
and start pureed foods and rice cereal.
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Discharge and ward review in 2days
Weekly GP and CCHN reviews planned
Plan of care agreed by family
Progress at Home - 1
Gained 95g in 2 days
(on120 Cal/kg/day feeding)
 Feeding a little better on breast now
 Refusing solids – strong tongue thrust and
not swallowing very well(spill noted)
 Weekly GP/CCHN review not yet started
 Weekly Paediatric follow-ups in place
 Home after ward review
 Feeding diary to maintain
(at least for 72hours)
 CCHN and GP informed (Letter & Phone)
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Progress at Home - 2
3 days before his review by paediatrician
in the OPD clinic he presented to a tertiary
care centre for “no improvements in feeding
behaviour and remaining unsettled” along
with high maternal anxiety.
He was admitted to infants ward
Referred to Gastroenterology unit
Assessment from Gastro team : Pending
What is the diagnosis now ?
Waiting in the hospital for an assessment !
Report from Gastroenterology Unit
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UPPER GI SCOPY: Oesophagus, antrum and
duodenum : Normal . Suggest Oesophageal pH
monitoring and barium swallow if not improving.
DISCHARGED PLANNING:
General Paediatric review in 2 weeks time
CCNH and GP review weekly (for weight gain)
Referred to feeding services
Home with feeding advice
Continue Omeprazole 5mg BD
Home with structured feeding plan
What Is Our Final Diagnosis?
ANSWER
Feeding Problem
Poor weaning
Suspected mild Oromotor incoordination
No tongue tie found
No organic disease found
PROGRESS AT HOME
Good and adequate weight gain over the next 4 weeks
Follow-up by GP, CCHN and Dietitian in the community
Discharged form specialist care
Growth Failure
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Failure to gain weight over time
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Weight below 3rd percentile(Australia) on more
than one occasion (a proper growth chart is used)
Weight crossing 2 or more major centiles lines
Weight for age <80% (<70% needs admission)
Weight for length <80% (not matching Wt and Ht)
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WHO growth charts for <2 years age (BF)
CDC growth charts for >2 years
Serial Wt/Lth/HC should be record by CCHN/GP
Weight faltering
• Weight below 3rd percentile for corrected GA and sex
on more than one occasion.
• Special growth charts used for: Down , Turner William,
Achondroplasia, Noonan and may include patients with
chronic diseases like CD ,CF, CHD & Chronic Infections.
• Weight less than 80 percent of ideal weight-for-age,
using a WHO/CDC growth chart.
• Low weight-for-length (weight for age < length for age,
weight-for-length <10th percentile ) .
• A rate of weight gain that drops two or more major
centile lines (90th, 75th, 50th, 25th, 10th, 5th and 3rd)
crossing over time. (e.g. from 75th to 25th ).
• A rate of daily weight gain less than the expected rate
for the age ( Can very with age and race)
OVERVIEW
OF
GROWTH FALTERIN (FTT)
AND
WEIGHT FALTERING
HISTORY
History gives a yield of 92%
Identification data (Age/Sex/Race/Address)
AN Hx and Birth Hx (Premmie-IUGR)/Neonatal problems
Development and Immunizations
Detailed Nutritional history
Observe formula preparation and BF time /Give test feed
Weaning Hx/ Past Hx of PEM/Condition of sibs/Hx Of
TORCHS (Congenital infections)
Housing/ Carers/Beliefs/ Food insecurity/Neglect
DCPFS involvement/Foster care
Family dysfunction/Unemployment/ DA/ DV /LIG
Hx from primary health care providers : CCHN/ GP/MW
Hx from SW/ DCPFS case worker /Dietitian/ CDC/MW
Physical Examination
Yield is positive in 8% of cases
Sick look/ Scrawny/ Low fat over arm/buttock
Irritable/Miserable/Lethargic/poor muscle mass/S/S
of NAI/Cues of interaction of child with parents/
Dehydrated child
Facies, HEENT, Skin, Mouth, Nose,
All major system assessment
Observe a feed
Interaction of care giver or parents with child
Aversive behaviour towards feeding
Coercive feeding : Even in sleep
Watchful look
Bruising
Oral lesions
Some Diagnostic Clues From Hx and P/E
Ex-Pre/IUGR/RTA/IEM/CD/CF /CHD/ CMPA/ DM
DI/ MAS/ PEM/ Hypothyroidism/ Genetic or
Syndromic clues/Munchausen-Syndrome by proxy
/GORD / IBD/acute or chronic Infections / D and V/
HIV/ TB/ poor height /NAI/UTI/Storage/EO/
Imported illnesses/ Surgical cause /Malignancy/
OSA/ Addison's disease/Respiratory problem/
Tropical illness/Constitutionally small/ Familial
small/ Ethnically small/ FASD/ nutritional
deficiencies / CP/ other minor neurological
issues/ASD.
Investigations
Investigations yield is positive in <1% of cases
Investigate the child as per diagnostic clues found
in history and physical examination
“No Fishing expedition” to request an investigation
All first line tests are simple and may be useful
and the yield is too low to justify a test
Oetiology of FTT
It is multifactorial with biologic, psychosocial and
environmental factors acting together
In 80% of cases there is no single medical reason
Most common cause of FTT is lack of energy
(food) intake due to Psychosocial/Environmental
reasons
Detailed physical examination may be
useful in diagnosing the cause of FTT
but
History remains
THE GOLD STANDARD
Investigation may rarely help
to reach a final diagnosis
Proportionality of Wt and Lth
1. Low weight centiles in proportion to length
centiles suggest an acute inadequate nutritional
intake and most likely an acute recent illness or
change in eating environment/psychosocial milieu.
2. Low length centiles in proportion to low weight
centiles suggests an organic, syndromic or long
term environmental nutritional inadequacy.
Weight faltering causes-Groups
Organic <1% (Old school)
 Non-organic >95% (Old school)
 Mixed >99% (New school)
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Endogenous
Exogenous
Mixed
Poor energy intake for any reason - Common
 Inadequate energy absorption – uncommon
 Poor energy assimilation – Rare
 Increased energy utilization – Rare
 Defective energy utilisation – Rare
 Other causes - Rare
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Weight faltering (Oetiology)-1
Inadequate intake
(Common)
 Feeding technique
 Economic, social,
Parental neglect/ Ignorance
 Poor Food content
 Mechanical e.g. cleft palate
Sucking or swallowing
dysfunction e.g. neurological
 Oro-motor dysfunction
 Prematurity
 IUGR
 Psychosocial/
 Maternal Deprivation
Syndrome
Inadequate absorption
(Uncommon)
 Malabsorption
Reflux : GORD
 Obstruction
Pyloric stenosis
 Previous surgery :
Short bowel syndrome
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Weight faltering (Oetiology) -2
Increased demand
(Rare)
 Hyperthyroid
 Chronic systemic illness
CHD, Chronic asthma,
JRA, CF and Other
respiratory illness
 RTA and CD
 Chronic infections TB
 Recurrent UTI
 Malignancy
Defective utilisation
(Rare)
Metabolic
Storage diseases and
Inborn errors of
metabolism
DM
DI
Investigations which might occasionally help
Urine : Metabolic Screen with GAG (IEM) AA/OA/Storage
 Liver biopsy- Storage diseases
 CXR/ AXR / MRI/ CT/PET
 Gastroscopy / Colonoscopy and Rectal biopsy
 Abdominal and Cranial Ultra Sound Studies
 Sucking and wallowing dynamic functions
 Oesophageal and gastric pH studies/ Gut biopsy
 Skeletal survey
 Coagulation studies
 Allergic tests: SPT/ Specific RAST/ Total Immunoglobulins
 Genetic studies : Microarray/ Chromosomal analysis
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Modern Management of growth faltering - 1
Multidisciplinary approach with a case conference
Improve overall nutritional status slowly
Provide adequate energy, proteins, oils, minerals (Zn
and Iron) and Vitamins (D and B complex)
Keep a Food diary/ Observe feeding closely/No
distraction during feeding times/ Support carers / No
confrontation /Food play therapy may be useful/ Ignore
food mess
 Avoid rapid weight gain ( give > 7 days for full catch
up growth rate to occur)
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Failed appointments consider SW or DCPFS referral
Infant require weekly and older child 2 weekly follow-ups
Modern Management of growth faltering - 2
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Active involvement of dietitian/ nutritionist/
SW/ Speech Pathologist / OT/ Feeding Team
Provide full support and dietary education to
care givers - parents / Help in finances and
attachment strategies/written treatment plan
Close follow-up with CCHN/ GP/ Community
Dietitian/ Refer to specialist if still poor growth
despite adequate calories provided
 Manage organic causes through specialists
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Consider referring to Feeding team/CDC
team, SW or DCPFS case worker.
Modern Management of FTT: Nutritional therapy-3
Catch-up weight gain: 2-3times greater than average
for the age of child with caloric intake given at
1.5times. Dietician to calculate energy and protein
needs with a written feeding and follow up plan.
 Add minerals (Zn/Iron) and vitamins(D/B) as required
 Target energy intake to reach by 7th day to avoid
re-feeding syndromes (low PO4…low K etc.)
 Parent or carer education is vital for success of
total nutritional rehabilitation .
 Never confront support person like parent or carer

Modern Management of Feeding : Environment - 4
 Position is important while feeding infants
 Food insecurity should be treated first (42% in LIG populations)
 Minimise distractions: TV /Mobiles/ Noises during feeding
 Relaxed and family oriented feeding time is vital for success
 Encourage but do not force eating
 No non scientific family beliefs to encourage
 Allow to play with food- Food play therapy is very useful
 Praise child when eating well but don’t punish if he/she does not
eat and even throws the food on floor. No coercive feeding to allow.
 Carer’s education and on going support is very important for
success of any good feeding plan.
 Address neglect and poor knowledge about foods carefully
 Involve any other family members (Grand mother) in feeding plan
 Regular and structured follow-ups in OPD/GP is very useful
 Centre of all care remains CCHN/GP/Dietitian team
Final word: Small Children
1. High percentage of infants with FTT will
still remain small for age in many populations
Risk of cognitive defects and behavioural
problems remains high in these groups
2. Many social and biological factors will persist
and impact on long term prognosis and
nutritional rehabilitation. Home visits and
support from NGOs may be useful in these
cases and even the support from DCPFS and
SW may be required in the long run.
Children and Adolescents :Most to least common causes of FTT
Mood disorder
Eating disorder
GORD
IBD
Food allergy
Celiac disease
Malabsorption
Inflammatory bowel disease
Inborn error of metabolism
Thyroid disease
Chronic infection or immunodeficiency
Chronic pulmonary disease
Congenital heart disease or heart failure
Malignancy
Infants and toddlers: Most to lest common causes of FTT
•
•
•
•
•
•
Breastfeeding problems
Improper formula preparation
GORD
Caregiver depression
Lack of food availability
Cleft lip or palate
•
•
•
•
•
Food allergy
Malabsorption
Pyloric stenosis
Gastrointestinal atresia or malformation
Inborn error of metabolism
•
•
•
•
•
Thyroid disease
Chronic infection or immunodeficiency
Chronic pulmonary disease
Congenital heart disease or heart failure
Malignancy
Red Flags in history and examination (requiring Investigations)
Cardiac findings (congenital heart disease or heart failure) like murmur,
oedema, jugular venous distention tachycardia low SpO2)
Respiratory findings (Asthma/ GORD/CF)
Developmental delay
Dysmorphic features
Failure to gain weight despite adequate caloric intake
Organomegaly / Lymphadenopathy
Recurrent or severe respiratory, mucocutaneous, or urinary
infection.
Recurrent vomiting, diarrhoea, or dehydration
Red Flags on History and Examination (Australian scene)
• Signs of abuse or neglect (NAI)
• Poor carer’s understanding e.g. non-English speaking,
intellectual disability, food insecurity, new immigrants
• Signs of family vulnerability e.g. drug and alcohol
abuse, domestic violence, social isolation, no family
support, refugee status
• Signs of poor attachment
• Parental mental health issues
• Already/previously case managed by child protection
services (DCPFS/SW) poor report from CCHN or GP
• Did not attend or cancelled previous appointment/s
• Signs of dehydration, poor hygiene and poor skin care
• Signs of frank malnutrition or significant illness
ANY QUESTIONS ?
IF NOT !
THAN
NEXT SLIDE PLEASE
PEARLS
MANY HEALTHY CHILDREN GROW ON CENTILE LINES AT THE TOP OR BOTTOM
OF THE GROWTH CHART AND MANY HEALTHY CHILDREN HAVE SMALL “DIPS”
ABOVE OR BELOW A PARTICULAR CENTILE LINE OR GROWTH CURVE.
IT IS COMMON FOR THERE TO BE NO SPECIFIC CAUSE FOUND FOR A CHILD’S APPARENT POOR
WEIGHT GAIN OR POOR GROWTH AND CENTILE ADJUSTMENT IN FIRST TWO YEAR
BIRTH WEIGHT IS NOT NECESSARILY REPRESENTATIVE OF THE GENETIC POTENTIAL FOR FUTURE
GROWTH. THERE IS NO CAUSE FOR CONCERN IF A BABY IS HEALTHY AND GAINING WEIGHT BUT
TRACKING ALONG A LOWER CENTILE THAN THAT OF THE BIRTH WEIGHT.
ALWAYS REMEMBER TO CORRECT FOR PREMATURITY (<37 WEEKS) UNTIL 24 MONTHS OF AGE.
A WELL LOOKING CHILD WITH NORMAL NEURODEVELOPMENTAL PROGRESS, WHO SHOWS
APPARENT ISOLATED POOR WEIGHT GAIN WITH NO SPECIFIC CAUSE EVIDENT FROM HISTORY,
EXAMINATION AND POSSIBLY SOME SIMPLE INVESTIGATIONS WILL HAVE AN EXCELLENT
PROGNOSIS FOR FUTURE HEALTH, WELLBEING AND DEVELOPMENT. FOLLOWS OWN CENTILE LINES
CONSTITUTIONALLY SMALL CHILD OF SMALL PARENTS IS NORMAL
THESE CHILDREN SHOULD BE MONITORED OVER TIME TO ENSURE THAT NO
SPECIFIC CAUSES OF POOR GROWTH BECOME EVIDENT
THERE IS ALWAYS A CATCH UP OR CATCH DOWN GROWTH IN FIRST 2 YEAR
Practice points
• The term FTT is used very broadly but has no strict definition
or clear outcomes if used as such without elaboration
• Comprehensive evaluation of weight faltering should be undertaken to
identify or rule out underlying disease and environmental factors.
• Most infants and young children with suspected growth faltering will be
normal constitutionally small children of small parents
• Our practice is to diagnose weight faltering in those children in whom we
identify underlying disease and/or environmental factors but mostly both .
Some of these children have associated nutritional deficiencies.
• Large, long-term cohort studies are required to investigate the effects of
FTT on future growth, behaviour and cognitive Development
REFERENCES:
1. HTTP://WWW.WHO.INT/CHILDGROWTH/STANDARDS/W_VELOCITY/EN/INDEX.HTM
2. HTTP://PATIENT.INFO/DOCTOR/CENTILE-CHARTS-AND-ASSESSING-GROWTH
3. COCHRANE DATABASE OF SYSTEMATIC REVIEWS, THE NATIONAL GUIDELINE CLEARINGHOUSE, THE TRIP
DATABASE, ESSENTIAL EVIDENCE PLUS, AND DYNAMED.
4. GOOGLE SEARCH USING GROWTH FALTERING AND WEIGHT FALTERING AND FTT
5. PUBMED SEARCH USING FTT
6. POOR GROWTH GUIDELINES FROM THE RCH MELBOURNE
7. DOH WA GUIDELINES ON WEIGHT GAIN AND FTT
8. HTTP://WWW.RCH.ORG.AU/GENMED/CLINICAL_RESOURCES/GROWTH_RESOURCES/
(SPECIAL GROWTH CHARTS)
9. WWW.RCH.ORG.AU/CHILDGROWTH/ (TO INTERPRET GROWTH)
10. CITY OF ROCKINGHAM OFFICIAL SITE - TOURISM
11. PAEDIATRICS AT A GLANCE 3RD EDITION 2012. MIALL, L; RUDOLF, M; SMITH, D. WILEY-BLACKWELL
12. WWW.EDUCATION.VIC.GOV.AU/CHILDHOOD/PROFESSIONALS/SUPPORT/PAGES/GROWTHCHARTS.ASPX
(GROWTH CHARTS)