2. Contents
Definition
Overview of Normal growth patterns
Epidemiology
Classification of FTT
Risk factors
Etiologies
Approach a child with FTT
Clinical manifestations
Assessment of FTT
Work UP
Severe Acute Malnutrition
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4. Definition
Failure to thrive (FTT) is a descriptive term
applied when a young child’s physical growth
is less than that of his or her peers
failure to attain the potentials expected for a
child of that specific age and sex
Sign of unexplained Wt lose or poor Wt gain
linear growth and head circumference also
may be affected
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5. Cont’d...
common terms to describe FTT;
Failure to gain weight
Failure to grow
Growth deficiency
Growth faltering
Undernutrition
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6. Cont’d...
Greatest Growth velocity of A Child
occurs at ;
First 2 years of life &
Earliest teens
It is at these times that the children most
probably fail to thrive.
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7. Cont’d...
The term FTT is not a disease
The best definition for FTT is the one that refers
to it as inadequate physical growth diagnosed
by observation of growth over time using a
standard growth chart
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8. The most common definition is weight less than
the 3rd or 5th percentile for age on more than
one occasion, or
weight measurements that fall 2 major
percentile lines using the standard growth
charts of the National Center for Health
Statistics (NCHS)
(MEDscape)
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9. Overview of Normal Growth patterns
Introduction
Normal growth is the progression of
changes in height, weight, and head
circumference that are compatible with
established standards for a given population
The progression of growth is
interpreted within the context of the
genetic potential for a particular child.
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10. Term infants: Lose 5-10% of birth Wt, regain by
10-14 days
Infant Wt gain pattern:
1kg/mo for the first 3 months
0.5kg/mo from age 3-6 months
0.33kg/mo from age 6-9 months
0.25kg/mo from age 9-12 months
Double the birth Wt by 4-6 mo
Triple the birth Wt by 1yr of age
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11. Cont....d
Normal growth is a reflection of overall health
and nutritional status.
Understanding the normal patterns of growth
enables
Early detection of pathologic deviations (eg, poor
weight gain due to a metabolic disorder, short
stature due to inflammatory bowel disease) and
Prevent the unnecessary evaluation of children
with acceptable normal variations in growth
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12. Growth velocity
The change in growth over time,
A more sensitive index of growth than is a
single measurement.
Current growth points should be compared to
previous growth points, if possible, to determine
the interval growth velocity
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13. Height velocity
Average normal length or height velocities are
as follows
0 to 6 months –--- (2.5 cm) per month
7 to 12 months – (1.25 cm) per month
12 to 24 months – (10 cm) per year
24 to 36 months – (8 cm) per year
36 to 48 months – (7 cm) per year
4 to 10 years ------- (5 to 6 cm) per year
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14. Head Growth
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Head circumference:
Average at birth is 35cm
47cm by 1yr of age, rate then slows
Average of 55cm by 6 yrs of age
Brain weight doubles by four to 6 months of age and
triples by one year of age
The majority of head growth is complete by 4 years of
age
15. Cont’d...
Corrections for gestational age should be made for
premature infant
– for weight through 24 months of age,
– for stature through 40 months of age, and
– for head circumference through 18 months of age
Special growth charts exist for some genetic disorders,
such as Down syndrome
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16. Exception to the definition
Children with genetically short stature, SGA
infants, and preterm infants
preterm infants: plot using corrected age
until 2yrs of age if birth Wt > 1000gm
until 3yrs of age if birth Wt < 1000gm
Catch-up growth for premature infants:
18mo for HC
24mo for Wt
40mo for Ht
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18. EPIDEMIOLOGY
True incidence of FTT is not known
In developed nations
5–10% of young children
3–5% of children admitted into teaching hospitals
Prevalence higher in developing countries , why?
Poverty
malnutrition
HIV infection
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19. Cont’d...
Under-feeding is the single commonest cause
of FTT
95% of cases of FTT inadequate food
peak incidence of FTT the age of 9–24 mo
No significant gender difference
Majority of children ≤18 months old
Uncommon after the age of 5 years
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21. Medical risk factors for FTT include;
prematurity
Intrauterine growth restriction(IUGR)
Developmental delay
Congenital anomalies (e.g., cleft lip and/or palate),
Intrauterine exposures (e.g., alcohol, anticonvulsants,
infection, lead poisoning, anemia) and
Any medical condition that results in inadequate
intake, increased metabolic rate, maldigestion, or
malabsorption
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22. Psychosocial risk factors for FTT include:
Poverty
Certain health and nutrition beliefs (e.g., fear of obesity
or cardiovascular disease, prolonged exclusive breastfeeding),
Social isolation
Life stresses
Poor parenting skills
Disordered feeding techniques
Drug or substance abuse
Other psychopathology
violence, and abuse
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24. Classification
Traditionally, classified as
1.Organic FTT
2○ to underlining medical illnesses
Account for less than 20% of cases
2.Nonorganic FTT (NOFT)
Psychosocial FTT
No known medical condition that causes poor
growth
Inadequate food or undernutrition
Accounts for over 70% of cases
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25. 3 . Mixed FTT
Organic and non organic causes coexist.
Those with organic disorders may also suffer
from environmental deprivation
Likewise, those with severe undernutrition
From non-organic FTT can develop organic
medical problems
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26. Cont’d...
Based on pathophysiology, FTT may be classified
into those due to:
1. inadequate caloric intake
2. inadequate absorption
3. increased caloric requirement, and
4. defective utilization of calories
This classification leads to a logical organization of many
conditions that cause or contribute to FTT; which is the
preferred classification,
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45. 1. History Taking
Prenatal History
Smocking
Alcohol consuming
Use of medication
Any illness during pregnancy
46. History
Postnatal History
Neonatal asphyxia/Apgar scores
Prematurity
Small for gestational age
Birth weight and length
Congenital malformations or infections
Maternal bonding at birth
Length of hospitalization
Feeding difficulties during neonatal period
47. History
Feeding history
Details breast and formula feeding
Typical feeding schedule, plus food preparation
(formula prep, portion size)
Methods of feeding, length of time spent feeding,
and diet supplementation/medication
Description of type of solid foods taken
(quantitative composition and frequency of meals
and snacks)
Prospective 3-day food diary
48. History
A direct observation- issues of sucking ability,
choking, regurgitation, vomiting, and diarrhea,
mother’s affect and attitude.
Change in formula, change from breast milk to
formula, and changes in the primary individuals
responsible for feeding the child
Parents’ attitude about feeding (restrictions of
food based on finances, religion
52. History
Age and occupation of parents
Who feeds the child?
Life stressors (loss of job, divorce, death in
family)
Availability of social and economic support
Perception of growth failure as a problem
History of violence or abuse of care-giver
53. Psychosocial History
Family composition
Any major events in the child’s life
Family stressors
Chronic Illness,
Martial stress
Single parenthood
Depression
Domestic violence
Substance abuse,
Employment / financial obligations
54. History
Growth and eating pattern of other siblings
Young parental age
Affluent circumstances or parents engaged in career
development
Child rearing beliefs
55. History
Poverty,
Certain health and nutrition beliefs (eg, fear of
obesity or cardiovascular disease, prolonged
exclusive breastfeeding),
Social isolation, life stresses,
Poor parenting skills,
Disordered feeding techniques,
Substance abuse or other psychopathology,
violence, and abuse
56. 2. Physical Examination
The four main goals of physical examination
include
1. Identification of dysmorphic features
suggestive of a genetic disorder that affects
growth
2. Detection of an underlying disease that may
impair growth
3. Assessment for signs of possible child abuse
4. Assessment of the severity and possible effects
of malnutrition
57. Physical examination
General appearance
Cachexia, temporal wasting, sparse hair or
alopecia malnutrition
Dysmorphic features
Small palpebral fissures
Midface hypoplasia
Flat philtrum
Thin vermilion border of fetal alchohol syndrome)
64. Red Flag Signs and Symptoms Suggesting
Medical Causes of Failure to Thrive
• Cardiac findings suggesting congenital heart disease
or heart failure (e.g., murmur, edema, jugular venous
distention)
• Developmental delay
• Dysmorphic features
• Failure to gain weight despite adequate caloric intake
• Organomegaly or lymphadenopathy
• Recurrent or severe respiratory, mucocutaneous, or urinary
• Infection
• Recurrent vomiting, diarrhea, or dehydration
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66. Most common clinical presentation is poor
growth
Accompanied by physical signs;
Alopecia
Reduced subcutaneous fat or muscles
Dermatitis
Syndromes of marasmus or kwashiorkor
67. Failure to meet expected age norms for ht and
wt
Recurrent infections
Depending on the severity infants with FTT
may exhibit
Thin extremities
Narrow face
Prominent ribs and wasted buttocks
68. Cont’d…
Neglect of hygiene
Diaper rash
Unwashed skin
Uncut and dirty finger nails or
unwashed clothing
Delays in social and speech development
Expressionless face and hypotonic
70. Anthropometric criteria:
1. A child younger than 2 years of age whose weight is
less than the 3rd or 5th percentile for age on > 1
occasion
2. A child younger than 2 years of age with weight is
less than 80% of the ideal weight for age
3. A child younger than 2 years whose weight for age
percentile crosses two major percentiles lines on a
standard weight curves below a previously
established growth rate
73. Growth Charts
• Standard growth charts are commonly used to
define how the growth of a child compares to
normal.
• Growth charts are constructed using a group of
normal children living:
–In a given area at a given time.
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74. Recommended growth charts
WHO growth charts :
For both boys and girls
• Weight-for-age
• Length-for-age
• Head circumference-for-age, and
• Weight-for-length
CDC/NCHS growth charts :
For both boys and girls
• Weight-for-age
• Length-for-age
• Head circumference-for-age, and
• Weight-for-length
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77. LABORATORY EVALUATION
Laboratory evaluation for organic disease should be
guided by the signs and symptoms found in the initial
evaluation.
A careful history and physical examination in the child
with failure to thrive (FTT) may suggest clues to an
organic disease
Laboratory studies that are not suggested on the basis
of the initial history and examination rarely are helpful.
One study revealed that only 1.4 % of the laboratory
studies performed in evaluating children with FTT were
useful diagnostically
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79. Severe Acute Malnutrition
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Child with visible severe wastingChild with edematous malnutrition
Severe acute malnutrition is defined by a very low weight for height
(below -3z scores of the median WHO growth standards), by
visible severe wasting, or by the presence of nutritional oedema
one of the most common causes of morbidity and mortality
among children under the age of 5 years WW
80. – Dx is made based on:
1. In infants < 6 months
WFH < 70%(Severe wasting) of NCHS median, OR
Bilateral pitting oedema of nutritional origin, OR
Visible Severe Wasting if it is difficult to determine W/L
2. children 6 months up to 5 years
WFH < 70%(Severe wasting) of NCHS median, OR
Bilateral pitting oedema of nutritional origin, OR
MUAC <11cm (for infants above 6months or >65cm length)
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