Failure to Thrive (Clinical Findings) PDF

AZERBAIJAN MEDICAL UNIVERSITY FAMILY MEDICINE DEPARTMENT Failure to thrive Clinical Findings Ph.D. Dr. Aygun Guliyeva  Symptoms and Signs  The importance of a complete, long-term growth curve in malting the diag...

AZERBAIJAN MEDICAL UNIVERSITY FAMILY MEDICINE DEPARTMENT Failure to thrive Clinical Findings Ph.D. Dr. Aygun Guliyeva  Symptoms and Signs  The importance of a complete, long-term growth curve in malting the diagnosis of FTT cannot be overemphasized. In acute undernutrition, the velocity of weight gain decreases while height velocity continues to be preserved. The result is a thin child of normal height. Chronic undernutrition manifests as “stunting”; both height and weight are affected. The child may appear proportionately small. Review of a growth curve may reveal that weight was initially affected and increase the suspicion for FTT. In interpreting growth charts, it is important to remember that healthy children may cross up to two major percentile lines up to 39% of the time between birth and 6 months of age and up to 15% of the time between 6 and 24 months of age. Children with length above the 50th percentile seldom have endocrine disease.  History  1. General history. The history and physical examination can uncover significant organ dysfunction contributing to growth failure. For example, the child who feeds poorly may have a physical impediment to caloric intake such as cleft palate or painful dental caries. Poor suck (ie, inadequate ability to suck) may also raise concerns for neurologic disease. Recurrent upper or lower respiratory tract infections may suggest cystic fibrosis, human immunodeficiency virus (HIV). or immunodeficiency. Sweating during feeding should prompt consideration of an underlying cardiac problem even in the absence of cyanosis. Chronic diarrhea can indicate malabsorption. Symptoms of chronic infection, eosinophilic disease, celiac disease, and pancreatic insufficiency should be elicited.  The healthcare provider must elicit more subtle aspects of past medical history as well, focusing particularly on developmental history and intercurrent illnesses. Delay in achievement of milestones should prompt a close neurologic examination. Inborn errors of metabolism and cerebral palsy can present with growth failure. A history of recurrent serious illness and FTT may be the only indicators of inborn errors of metabolism. Recurrent febrile illness without a clear source may also indicate occult urinary tract infection. A history of snoring or sleep disturbances should prompt an evaluation for tonsillar and adenoidal hypertrophy, which has been identified as a cause of FTT.  History  Past medical history must include a complete perinatal history. Children with lower birth weights and those with specific prenatal exposures are at higher risk for growth problems. Of all children with diagnosed FTT, 40% have birth weights below 2500 g; only 7% of all births are below 2500 g. Low birth weight may be caused by infection, drug exposure, or other maternal and placental factors. The child with symmetric growth retardation is of particular concern. Infants exposed in utero to rubella, cytomegalovirus, syphilis, toxoplasmosis, or malaria are at high risk for low birth weight, length, and head circumference. These measurements portend poor catch-up growth potential. Short stature is often accompanied by developmental delay and mental retardation in these children.  History  Children with asymmetric intrauterine growth retardation (preserved head circumference) have better potential for catch-up growth and appropriate development. Fetal growth is affected by both maternal factors and exposure to toxins. Drugs of abuse such as tobacco, cocaine, and heroin have been correlated with low birth weight. Placental insufficiency caused by hypertension, preeclampsia, collagen vascular disease, or diabetes may result in an undernourished baby with decreased birth weight. Finally, intrauterine physical factors may reduce fetal growth; uterine malformation, multiple gestation, and fibroids may all contribute to smaller babies. Maternal HIV infection is also a significant risk factor for FTT. Most children born to HIV-positive mothers have normal birth weights and lengths. However, children who are infected frequently develop FTT within the first year of life. Family history is essential. A family history of atopy, eczema, or asthma raises the suspicion of eosinophilic enteritides. A family history of autoimmune disease should heighten the concern for celiac disease. Metabolic diseases are generally recessive, and an absence of family history should not be regarded as reassuring.  History  2. Feeding history - A careful feeding history is part of the history of present illness. It often sheds more light on the problem than a battery of laboratory tests. When assessing an infant, it is essential to know what formula the infant is taking, in what volume, and how frequently. Caregivers should describe the preparation of formula. Caregivers may be inadvertently mixing dilute formula. In calculating caloric intake, the practitioner should remember that breast milk and formula have 20 cal/oz. Baby foods range from 40 to 120 calories per jar. An 80-cal/4-oz jar is a good average to use when malting calculations. The examiner should ask how long it takes the baby to eat; slow eating may be associated with poor suck or decreased stamina secondary to organic dysfunction. Parental estimation of the infant's suck may also be helpful. Parents should be asked about regurgitation after eating. The clinician should also inquire about feeding techniques. Bottle propping may indicate a poor parent-child relationship or an overtaxed parent.  History  The breastfed baby merits special mention. The sequelae of unsuccessful breastfeeding are profound. Infants may present with severe dehydration. Parents rarely recognize that the infant is failing to thrive. Mothers are often discharged from the hospital before milk is in and may be unsure about what to expect when initially learning how to breastfeed. The neonatal period is the most critical period in the establishment of breastfeeding. The primary care provider should educate the breastfeeding mother prior to hospital discharge. Milk should be in by day 3 or 4. The neonate should feed at least 8 times in a 24-hour period and should not be sleeping through the night. A "good" baby (an infant who sleeps through the night) should raise concerns of possible dehydration. Breastfed babies should have at least six wet diapers a day. Whereas formula-fed infants may have many stool patterns, the successful breastfed neonate should have at least four yellow seedy stools a day. After 4 weeks of life, the stool pattern may change to once a day or less.  History  Breastfed babies should be seen within the first week of life to evaluate infant weight and feeding success. Weight loss is expected until day 5 of life. Infants should regain their birth weight by the end of the second week of life. Any weight loss greater than 8% should elicit close follow-up. Weight loss greater than 10-12% should prompt an evaluation for dehydration. Primary care providers should ask about the infant's suck and whether the mother feels that her breasts are emptied at the feeding. The successful infant should empty the mother's breast and be content at the end of the nursing session. When breastfed infants are not gaining weight, it may be useful to observe the breastfeeding or obtain consultation with a lactation specialist.  The evaluation of older children also requires a thorough diet history. An accurate diet history begins with a 24-hour diet recall. Parents should be asked to quantify the amount of each food that their child has eaten. The 24-hour recall acts as a template for a 72-hour diet diary, the most accurate assessment of intake; the first 48 hours of a diet diary are the most reliable. All intakes must be recorded, including juices, water, and snacks. The child who consumes an excessive amount of milk or juice may not have the appetite to eat more nutrient-rich foods. A child needs no more than 16-24 oz of milk and should be limited to < 12 oz of juice per day.  Physical Examination  In addition to reviewing the growth curve, the clinician must complete a physical examination. A weight, length, or height, as appropriate for the child's age, and head circumference are indicated for all children. Growth parameters may be roughly interpreted using the following guidelines: Acute undernutrition: low weight, normal height, normal head circumference Chronic undernutrition: short height, normal weight for height, normal head circumference Acute or chronic undernutrition: short height, proportionately low weight for height, normal head circumference Congenital infection or genetic disorder impairing growth: short height, normal to low weight for height, small head circumference  Physical Examination o Children with undernutrition often have objective findings of their nutritional state. Unlike the genetically small child, children with FTT have decreased subcutaneous fat. If undernutrition has been prolonged, they will also have muscle wasting; in infants, it is easier to assess muscle wasting in the calves and thighs rather than in the interosseous muscles. It is also important to remember that infants suck rather than chew; therefore, they will not have the characteristic fades of temporal wasting. Nailbeds and hair should be carefully noted because nutritional deficiencies may cause pitting or lines in the nails. Hair may be thin or brittle. Skin should be examined for scaling and cracking, which may be seen with both zinc and fatty acid deficiencies. Presence of eczema may indicate allergic diathesis and eosinophilic enteritis.  Physical Examination o The physical examination should be completed with special attention directed to the organ systems of concern uncovered in the history. However, examination of some organ systems may reveal abnormalities not elicited through history. A thorough abdominal examination is of particular importance. Organomegaly in the child with FTT suggests possible inborn errors of metabolism and requires laboratory evaluation. The examiner should note the genitourinary examination. Undescended testicles may indicate panhypopituitarism, and ambiguous genitalia may indicate congenital adrenogenital hyperplasia. A careful neurologic examination may reveal subtly increased or decreased muscle tone consistent with cerebral palsy and, therefore, increased caloric requirements or inability to coordinate suck and swallow, respectively.  Laboratory Findings o Tests that had been advocated as markers of nutritional status have limitations. Albumin has an extremely long half life (21 days) and is a poor indicator of recent undernutrition. Prealbumin, which has been touted as a marker for recent protein nutrition, is decreased in both acute inflammation and undernutrition. Children with more severe malnutrition may be lymphopenic (lymphocyte count