Professional Documents
Culture Documents
THRIVE
Learning outcomes
Identify normal growth pattern in an infant
Define and discuss the causes of failure to thrive
in an infant
Demonstrate the importance of a feeding history
Explain the principles of infant nutrition
Plot and interpret the growth parameters on a
growth chart
Describe the nutritional requirements of normal
growth
Formulate the approach to management of a child
with failure to thrive
HISTORY TAKING
Chief complaint
Patient M, a 10 month old girl
presented to HKL with
- Fever
- Cough
3 days
Allergic history
Allergic to formula milk rashes
Birth history
Born in Klinik Mesra, Gombak
Delivered at term with birth weight of
2.6kg
No NNJ
No NICU admission
*perinatal history incomplete as
patient was an orphan
Diet history
Had a history of feeding difficulties since birth.
- Reduced milk intake since birth (3 oz 2 hourly)
- Takes longer time to finish her milk ( up to 1
hour)
- Associated with sweating
Exclusive breastfeeding up to 1
month old.
Took formula milk since then.
Developed allergies (rashes) but no
diarrhea or vomiting
Changed to Isomil at 3 months old
after consulting physician at Hospital
Ampang.
Drug history
Syrup Furosemide ( 7 mg tds )
Syrup Spironolactone ( 6.25 mg )
Syrup Captopril ( 0.6 mg tds )
Family history
23 y/o
Indonesian
Patient M,
10 months old
Immunization history
Completed up to date
No post-immunization complications
Social history
Stays in rumah kebajikan Nur Hidayah
Mother passed over care of child to
centre after patient was 1 month old.
Mother currently not staying in
Malaysia
Father could not be traced either.
No financial restrains in caring for the
Developmental history
Components
Actions
Gross motor
Attentive to people
Mature pincer grasp
Able to find partially hidden toy
Object permanence
Watches falling toy in field of
vision
DEVELOPMEN
TAL AGE :
Hearing
and speech
10
MONTHS Shouts for attention
Social behavior
Plays peek-a-boo
PHYSICAL
EXAMINATION
General Examination
Alert & active, pink, no dysmorphic features, not in respiratory
distress
Cyanosed during crying but no peripheral cyanosis
No clubbing, leuconychia, palmar erythema, bruises, rash
No conjunctival pallor or jaundice
Hydration status was fair
No muscle wasting
No pitting oedema
Pulse rate: 142 beats/min, good volume, normal rhythm, no
radial-radial and radial-femoral delay
Respiratory rate: 32 breaths/min
Blood pressure: 104/50 mmHg
Temperature: 36.5 C
length: 68cm (25th centile)
Weight: 6.7kg (3rd centile)
Head circumference: 43cm (25th centile)
Cardiovascular Examination
No scar or chest deformity
Apex beat is palpable at 5th intercostal space on the left midclavicular line. displaced
There is a palpable thrill at left sternal edge
No parasternal heave
1st and 2nd heart sounds were heard
Pansystolic murmur at left sternal edge, radiation to the right
sternal border, Grade 4/6
Respiratory Examination
No scar, prominent vein, no chest deformity (pectus
excavatum, pectus carinatum)
No intercostal or subcostal recession
Cervical lymph nodes were not palpable
Apex beat was displaced
There was good air entry bilaterally. Vesicular breath
sounds, no added sounds.
Abdominal examination
Abdomen was not distended, soft, non-tender, moves with
respiration
No scar, dilated vein, swelling
Umbilicus was centrally located, inverted
No hepatosplenomegaly
Kidney is not ballotable
Bowel sound is heard, normal tone
Neurological Examination
Peripheral nervous system was intact
All cranial nerves were intact
INVESTIGATION
Chest radiology
Cardiomegaly
Hyperinflated chest with perihilar haziness
Echocardiography
Peri-membranous ventricular septal defect (+
3mm)
Clinical summary
Patient M, a 10 month old girl with a history of recurrent
chest infections, presented with intermittent fever
unresolved with syrup PCM, associated with a sharp, dry
cough for 3 days. Diagnosed with having VSD 3 months
ago. She had poor feeding since birth which
deteriorated for the past 2 months. During feeding,
there was perioral cyanosis, sweating, rapid breathing
.
On examination, the apex beat is displaced. There was a
pansystolic murmur graded 4/6 best heard at the left
sternal edge which did not radiate.
Echocardiogram showed a peri-membranous ventricular
septal defect
Provisional diagnosis
Ventricular Septum Detect, currently
in failure, with acute bronchiolitis
MANAGEMENT
Problem :
1.Feeding difficulties
2.Recurrent chest infection
3.VSD in failure
1. Feeding difficulties
Review by the dietitians :
Energy needed : 150 kcal / kg / day
Protein needed : 4 mg / kg / day
Advice carer on high protein and high calorie diet.
To increase high milk dilution in view of patient not taking
much (small volume/feed).
- (1 and half scoops of Isomil in 2 oz / 2 hours x 10 bottles
per day)
To add potato/ pumpkin in porridge daily
- Rice porridge (1 cup per meal ) for lunch and dinner +
chicken/ fish ( 1 matchbox size/ day) + vegetables +
potato/pumpkin (1 exchange/ day) + oil (1 tablespoon/
meal)
To encourage intake of biscuits / bun as tolerated.
Prevention
Avoid over crowding.
Avoid contact with the infected person.
3. VSD in failure
Syrup Furosemide ( 7 mg tds )
Syrup Spironolactone ( 6.25 mg )
Syrup Captopril ( 0.6 mg tds )
IDENTIFY NORMAL
GROWTH PATTERN IN
AN INFANT
WEIGHT
Newborn normally will lose 10-15% of their birth weight due
to:
I. Excretion of excess extravascular fluid
II. Possibly poor intake (intake improves as colostrum is
replaced by higher fat milk, as infant learn to latch on and
suck more efficiently, and as mother become more
comfortable with geeding technique)
.
.
.
. Weight gain :
0-3 months - 1.0 kg/month
3-6 months - 0.5 kg/month
6-9 months - 0.33kg/month
HEAD CIRCUMFERENCE
At Birth AGE
0-3 mo
2.00
3-6 mo
1.00
6-9 mo
0.50
9-12 mo
0.50
1-3 yr
0.25
4-6
1cm/yr
LENGTH
Preterm infants = average 0.81.0cm/week.
Term infants
= average 0.69Age
Length
0.75cm/week.
Birth
50cm
6 months
68cm
1 year
75cm
3 years
90cm
4 years
5 12 years
5 cm yearly
INTERPRET GROWTH
PARAMETERS ON A
GROWTH CHART
Weight
10th centile at birth till 1 month
Drop to between 3rd to 10th centile for the
next 2 months
On the 3rd centile during 6th month of life
Below 3rd centile during 9th and 10th
month of life
DEFINITION
Given to malnourished
infants & young
children who fail to
meet expected
standards of growth :
Fails to gains weight /
length / head size /
development.
Related to organic,
environment and
psychosocial causes.
Nelson, essential of Peadiatrics, 6th edition.
DEFINITION
Suboptimal weight gain in infants and
toddlers
Inadequate weight gain when plotted on a
centile chart
Mild FTT Fall across 2 centile lines
Severe FTT Fall across 3 centile lines
Illustrated textbook of peadiatrics, 4th
edition
DIAGNOSED BY:
Infections
Neurologic
Congenital /
anatomic
Metabolic
Renal
Environment
al
GASTROINTESTINAL CAUSES
GERD
Malabsorption syndromes
Celiac disease
Pancreatic insufficiency (cystic fibrosis)
Hepatobiliary causes (biliary atresia)
Hirshprung disease
INFECTIONS
Parasitic infections
URTI (pharyngitis, tonsillitis, otitis media, etc.)
UTI
Sinusitis
HIV/ immune deficiency
NEUROLOGICAL
1. Cerebral palsy
2. Neuromuscular disease
3. Degenerative and storage disease
Congenital causes
Chromosoma
l disorder
Down
Syndrome
(Intrauterine
growth
restriction)
IUGR
Congenital
infection
Extreme
prematurity
Cleft palate
Metabolic causes
Congenital hypothyrodism
Storage disorder
Amino and organic acid disorder
Renal cause
Chronic renal failure
Non- organic/environmental
Inadequate
Feeding problems
availability
of food
insufficient breast
milk or poor
technique,
incorrect
preparation of
formula
Infant difficult to
feed resist
feeding or
disinterested
Insufficient of
unsuitable food
offered
Lack of regular
feeding times
Conflict over
feeding,
intolerance of
normal feeding
behaviour
Cooking problem
and famine
Low
socioeconomic
status
Poor
maternalinfant
interaction
Psychosocial
deprivation
Maternal
depression
Poor
maternal
education
Neglect or child
abuse
Includes factitious illness
deliberate
underfeeding to
generate failure to thrive
DEMONSTRATE THE
IMPORTANCE OF A
FEEDING HISTORY
Feeding history
Types of
feeding :
Breastfeeding
Formula feeding
Weaning
Breastfeeding history
History
Comments
2. The duration of
exclusive breastfeeding
and mixed breastfeeding
Demand or timed
Well term babies should be given breast
feed on demand. (usually 8-12 times/day)
4. Strength of sucking
5. Any difficulty in
breastfeeding
Comments
Infant, special, soy formula
Weaning
History
Comments
EXPLAIN THE
PRINCIPLES OF
INFANT NUTRITION
Calorie requirement:
Term infants : 110 kcal/ kg/ day
Preterm infants : 120-140 kcal/
kg/ day
WHO recommends the following:
1. Exclusive breastfeeding for the first six months
of life to achieve optimal growth, development
and health
2. Infants should receive nutritionally adequate
and safe complementary foods while
breastfeeding continues for up to two years of age
or beyond.
Types of feeding
1. Breastfeeding exclusive (0-6 months)
-Milk of choice
-Term healthy infants should be breast fed asap within the first
hour.
- Human Milk Fortifier (HMF)
*add to expressed breast milk in babies < 32 weeks or <
1500g.
*give extra calories, vitamins, calcium and phosphate
2. Formula feeding(modified cows milk)
- Only be given if there is no supply of breast milk
- Unmodified cows milk
*unsuitable
*too much protein and electrolytes
*inadequate iron and vitamins
a)Preterm Formula : for babies born <32 weeks or < 1500g
b)Normal Infant Formula
: For babies born >31 weeks or >
1500g
3. Specialised infant formula
- Cows milk-based formulas
- Soy formulas
DESCRIBE THE
NUTRITIONAL
REQUIREMENTS FOR
CHILDREN
INTRODUCTION
1. Nutrient needs determined by:
Body size
Growth rate
Age
Nutrient Recommendations
Based on Malaysian Dietary
Guideline (MDG) 2010:
Key message 12:
Practice exclusively breastfeeding
from birth until six months and
continue to breastfeed until two
years of age.
Key recommendations:
Fruits
Vegetables
Milk
ORGANIC FAILURE TO
THRIVE
Direct practical
advice following
observation
Paeds dietician
- Assess quantity &
composition of food
intake
- Recommend
strategies to increase
E intake
Clinical psychologist
& social services
Nursery placement
- Alleviate stress at
home
- Assist feeding
Limit intake of :
water
juice
Emphasize intake of : highcalorie foods
soda
peanut butter (??)
low-calorie
beverages
whole milk
cheese
dried foods
High-calorie liquids :
High-calorie
supplementation Carnation Instant
breakfast with whole
:
milk
Duocal
Formulas containing
Polycose
>20cal/oz Pediasure,
THANK YOU!