FAILURE TO THRIVE

BY :
ABDUL HAFIZ ALIAS
060100846

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 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 2
major percentile lines using the standard
growth charts of the National Center for
Health Statistics (NCHS) in a short time.
• true malnutrition (weight <80% of ideal body
weight for age) 2
 Normal growth in term
infants

Average birth weight for a term infant is 3.3 kg.

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

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Weight/day g/day
0-3 mths 26-31
3-6 mths 17-18
6-9 mths 12-13 Height/yr cm/year

9-12 mths 9 1st 25

1-3 yrs 7-9 2nd 12.5

4-6 yrs 6 4th - onset 5-6

of puberty
Puberty 12
onwards
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 Head Average
circumference (cm)
(year)
Birth 35 upper-to- Average(cm)
lower body
1st 47 segment
ratio
Birth 1.7
2nd 49

6 th
55 1st 1.3

7th 1.0
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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 Prematurity with complications
Maternal malnutrition
Toxic exposure in utero
Alcohol, smoking, medications,
infections
IUGR
Chromosomal abnormalities
Postnatal causes Inadequate intake
Poor absorption and/or use of
nutrients
Increased metabolic demand

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 COMBINATION
• Chronic illness + social pressure
• children with asthma, heart disease,
and CP all have organic reasons for
failure to thrive.
• In addition, the social pressures
(parental dysfunction, medications,
poor compliance) that children with
these conditions experience can
cause behavioral changes that
result in decreased energy intake
and, therefore, failure to thrive.
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HISTORY
• Prenatal 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
organic 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 • Human
• Urinalysis immunodeficiency
• Urine culture virus (HIV) testing
• Sweat chloride test
• Electrolytes, including
creatinine and BUN • Thyroid function tests
• Liver function tests, • Stool studies for
including total protein parasites or
and albumin malabsorption
• Prealbumin may be • Immunoglobulins
used as a nutritional • Purified protein
marker derivative (PPD) skin
• Serum insulinlike test
growth factor I (IGF-I) • Radiological studies
• Insulinlike growth
factor binding protein
(IGF-BP3)
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19
 DIET
• Long-term goal for every child with failure to thrive is to
provide adequate energy intake for growth!!!
• Infants may be given concentrated formulas, assuming
renal function is normal
• In toddlers, supplemental high-energy formulas as much
as 30 kcal/oz are used.
• Supplements for older children may include adding
cheese, sour cream, butter, margarine, or peanut butter
to meals.
• High-energy (approximately 1 kcal/mL) shakes
• Multivitamin and mineral supplements, including iron and
zinc, usually are recommended to all undernourished
children.
• In children with organic failure to thrive, continuous
nighttime tube feeding also may be used to increase
their energy intake.
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PROTEIN ENERGY
MALNUTRITION

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 Definition of Malnutrition

• The cellular imbalance between the

supply of nutrients and energy and
the body's demand for them to
ensure growth, maintenance, and
specific functions. (WHO)

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• Protein: deficit in amino acids needed for cell
structure, function
• Energy: 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-energy
malnutrition.
• Approximately 50% of the 10 million deaths each year
in developing countries occur because of malnutrition
in children younger than 5 years. In kwashiorkor,
mortality tends to decrease as the age of onset
increases.
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 PEM

PRIMARY SECONDARY

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 Marasmus
•Severely wasted
(emaciated) & stunted
•“Old 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
•Edema
•Mental 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-Kwashiorkor

• edema occurring in children

who are otherwise marasmic
and who may or may not have
other signs of kwashiorkor.

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 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.
• Kwashiorkor 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 intervention.
• Detailed dietary history, growth measurements, BMI are
essential
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PHYSICAL EXAMINATION

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INVESTIGATIONS
• 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
• Serum albumin
• HIV test
• Electrolytes

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 ...significant findings
• hypoalbuminemia (10-25 g/L) • In both kwashiorkor and
• hypoproteinemia (transferrin, essential marasmus, iron deficiency
amino acids, lipoprotein) anemia and metabolic acidosis
• Hypoglycemia are present.
• Plasma cortisol and growth hormone • Urinary excretion of
levels are high, but insulin secretion
and insulinlike growth factor levels are hydroxyproline is diminished,
decreased. reflecting impaired growth and
• The percentage of body water and wound healing.
extracellular water is increased. • Increased urinary 3-
• Electrolytes, especially potassium and methylhistidine is a reflection of
magnesium, are depleted. Levels of muscle breakdown and can be
some enzymes (including lactase) are seen in marasmus.
decreased • Malnutrition also causes
• circulating lipid levels (especially immunosuppression, which may
cholesterol) are low. result in false-negative tuberculin
• Ketonuria and a decrease in the skin test results and the
urinary excretion of urea because of subsequent failure to accurately
decreased protein intake.
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 4
g/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 gruels with milk, oil, sugar soft
• Soft ripe fruit, cooked vegetables
• Establish a daily, graduated intake of -
• ~3-4 g protein per kg (actual) body wt
• ~200 kcal of energy per kg body wt

V Reddy, Protein Energy 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 large
meals
• Micronutrient supplements:
• To treat clinical conditions (eg, anemia,
xerophthalmia)
• To prevent further deficiencies
• Water for thirst
• Treat infections and illnesses; eg,
• Diarrhea: ORS & zinc
• Antibiotics, as indicated
• Prevent hypothermia
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 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. Permanent 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 !