Failure to thrive

Faltering of growth
Growth deficiency
Persistent weight loss
.

2016

Aims
1. Having an overview about normal and
abnormal growth.
2. Understanding growth charts.
3. Background regarding nutrition & nutrients.
4. Nutritional assessment

(Hx. , Examination,

Investigations).

5. Malnutrition causes ,types and classification.

6. D/D of FTT malnutrition (an outline).

What is normal growth?

Definitions
Growth
It is the increase in size of any living
being or it`s parts.
Normal growth
When living being grow at the expected
rate (following the normal pattern for
growth).

What is Abnormal growth(FTT)?

1. Growth deceleration (Slower rate).
2. Faltering growth (Not progressing ).
3. Weight loss (Decreasing).
Simply abnormal growth is
Failure to grow at the expected rate
= F.T.T.

Failure to thrive (FTT)

1. It is a descriptive( )term NOT a
diagnosis.
2. Used for children whose attained
weight or rate of weight gain is
significantly below their expected age,
gender and ethnicity matched
controls.
3. FTT is a sustained loss of weight ,
failure to gain weight or a persistent
fall in weight from the childs normal
centile.

Again Remember
1. Failure to thrive (FTT) is not a diagnosis in
itself . It is a sign of poor growth due to
several (tens to hundreds)causes.
2. FTT could be due to more than one cause.
3. FTT is NOT always due to food deficiency:
Genetics , illnesses , mental health of
caregivers, and the home environment
ANY may play a role .
4. The medical causes of FTT may involve
any organ system or it could be NON
organic.

Criteria for failure to thrive

1.
2.
3.
4.
5.
6.
7.

Attained growth()
Weight <3rd percentile on standard growth chart.
Weight for height <5th percentile on standard
growth chart.
Weight 20% or more below ideal weight for height.
Rate of growth ( )
Less than 20 g/day from birth to 3 months of age.
Less than 15 g/day from 3 to 6 months of age.
Fall off from previously established growth curve.
Downward crossing of >2 major percentiles.

Anthropometric criteria of FTT

1. Major percentile line on the growth charts
(below the 3rd. or 5th. percentile)
2. Standard deviation from the mean
weight/height.
3. Percentage of median( standard, expected):
{(actual wt. median wt.)/median weight }
100)
4. Z (Standard deviation , SD) scores, that
express anthropometric data normalized for
age and sex {(observed weight median
weight)/standard deviation of reference
population}.

Nutrients and Nutrition

Macronutrients (The main 3)
1. Energy providers :
Carbohydrates, fats.
2. Body builders : Proteins.

Micronutrients
Micronutrients are essential dietary
components, cannot be synthesized by the
body on a daily basis

Micronutrients are composed of

A. Organic substances (fat and water
soluble vitamins).
B. Inorganic (minerals and trace
elements).

Micronutrients
Functions
A. Tissue structure (e.g vit A & C epithelial &
immune) .

B. Enzyme systems.
C. Fluid balance.
D. Cellular function.
E. Neurotransmissions.

Nutrients and Nutrition

The four main parameters generally used for
nutritional assessment of a child are:
1. Anthropometry (Wt., Ht./Lt., OFC).
2. Dietary (feeding Hx).
3. Clinical (Examination).
4. Biochemical(Investigations).
You will focus on these but you will handle
the child
as usual
(Hx. , Examination , Investigation
,Treatment)

What is Malnutrition?
1. It is an imbalance between the intake
and absorption of nutrients and the
rate at which the nutrients are used.
2. This imbalance can lead to both under
nutrition ( FTT) and over
nutrition(obesity), both are
malnutrition.

Growth charts
Each chart is composed of percentile
curves, representing the crosssectional distribution of weight,
length, head circumference, etc. at
each age.
The percentile curve indicates the
percentage of children at a given age
on the x-axis whose measured value
falls below the corresponding value
on the y-axis (The measurement).

Growth charts
The median or 50th percentile is
also termed the standard(or
expected)value ( Wt., Ht., OFC,
etc.) , in the sense that the
standard(expected) measurement
for that age is that value.

Growth charts
The World Health Organization (WHO)
released growth charts based on
the Multicenter Growth Reference
Study for young children in 2006
and for children 5-19 in 2007.
The 6 study centers representing 5
continents (( were
included: United States, Brazil, Norway,
Ghana, Oman, and India.

Growth charts
Studies have shown small ethnic
differences among groups, just as there
are genetic differences among
individuals, but for practical purposes
they are not considered large enough to
invalidate the general use of the WHO
growth standards population as a
universal standard.

Malnutrition Classification

Interpretation of Percent of Ideal Body Weight

1. >120%>>>>>>>>>>>Obese.
2. 110-120% >>>>>>>>>Overweight.
3. 90-110% >>>>>>>>>>Normal variation.
4. 80-90% >>>>>>>>>>>Mild wasting.
5. 70-80% >>>>>>>>>>>Moderate
wasting.
6. <70% >>>>>>>>>>>>Severe wasting.

Malnutrition Classification

Interpretation of Percent of Ideal Body Weight

Current weight ( Ideal weight for the height
percentile).
A. Ideal Wt. for Ht. =
1. Measure the height or length and see at what
percentile .
2. Look at the ideal weight at that height percentile .
B. Percent of Ideal Body Weight =

Divide the current weight by the ideal weight for height

X 100.

Classification of severe malnutrition

Clinically : Marasmus, kwashiorkor, and
marasmic-kwashiorkor.
Marasmus:
1. usually seen within the first year of life. a
predominantly caloric/energy deficiency with
wasting of tissue.
2. It is a consequence of poor caloric, protein,
vitamin, and mineral intake.
3. marked weight-for-height reduction .
4. Emaciation.
5. loss of subcutaneous fat.
6. lusterless and sparse hair.
7. poor nail growth .

Classification of severe malnutrition

kwashiorkor
1. Results from a diet rich in calories but lacks protein.
2. Oedematous.
3. Hepatomegaly and mental status changes are
common.
4. Skin changes in kwashiorkor patients include
hyperpigmentation and hypopigmentation with a
scaly, weeping dermatitis that may ulcerate and
desquamate .
5. It resembles pellagra but is seen in areas that are
not exposed to sunlight.
Marasmic-kwashiorkor ( protein-energy malnutrition ) .
6. Both patterns of malnutrition develop together,
resulting in a combination of clinical features.

Marasmus & kwashiorkor

Common signs of malnutrition

A. Macronutrients deficiencies
1. CHO: Moon face (kwashiorkor) vs. wasted
(Marasmus) , lethargy(energy lacking)
2. Lipid(fat):Loss of SC fat (Abdomen-Buttocks-- cheeks)
3. Protein: Wasting ,Oedema , nail white
lines.

Common signs of
malnutrition

B. Micronutrients deficiencies ( head to toe)

1. Hair: Dry , lustreless ,sparse ,alopecia(loss).
2. Eyes: Dry , Lustreless , Bitot spots (Conjunctival
shiny gray lesions ) , Jaundice.
3. Lips& mouth: Angular fissure(cheilosis=angular
stomatitis) , Stomatitis(smooth tongue) , Ageusia
(tasteless).
4. Skin: Follicular hyperkeratosis(prominent follicles) ,
rashs(generalised/localised,exposede /covered) ,
petechiae , dyspigmentation (hypo/hyper) ,
Dermatitis.
5. Bones(Head , chest , limbs): swelling, tenderness,
deformatity, fractures.

Common signs of
malnutrition
B. Micronutrients deficiencies ( head to
toe)
6. Nails: undergrowth , lines , deformities.
7. Chest wall: Deformities , ricktetic
rosaries.
8. Heart: C.H.F.
9. Abdomen & genitalia: Delayed sexual
development , distension ,
Hepatomegaly.
10.CNS:

Common signs of
malnutrition

Focused history taking

Like every other complaint

Onset (when started when she

noticed?)
Progress ( comparing with the start :
the same , better, worse (what is worse
for mother may be better medically =
always clarify).
Relievers & Triggers (start with open
questions ,then with directional
questions)

FTT focused history taking hints

1. The onset and progress of the growth
failure.
2. The quantity, quality and frequency of
feeds & meals.
3. Many children with FTT will be because
of deprivation and/or psychological
problems.So , look for risk factors:
A.
B.
C.
D.

Poverty.
Family conflict.
social isolation.
caregiver mental health issues.

FTT focused history taking hints

4. Medical causes of FTT could be caused by
and involve any organ system . Hence the
importance of systematic review and
approach.
5. Symmetrical growth failure(Wt. , Ht. , & OFC)
since birth usually due to Prenatal causes:
A. A chromosomal abnormality.
B. Intrauterine infection.
C. Teratogen exposure.

FTT focused history taking hints

6. Inborn error of metabolism must be considered
as a possible cause of FTT if any of the following
present:
A. History of acute, severe, and potentially life
threatening symptoms.
B. Unexplained recurrent vomiting.
C. Liver dysfunction.
D. Neurologic symptoms.
E. Cardiomyopathy and myopathy.
F. Impairment of special senses.
G. Renal symptoms.
H. Dysmorphic features .
I. Organomegaly.

Physical examination in cases of FTT

1.
2.
3.
4.
5.

Head to Toe.
Hair(dry,sparse,depigmented,loss)
Head& face(A.fontanel,Bossing,Craniotabes)
Eyes (palor,jaundice,Bitot spots,cornea)
Chest&
abdomen(Deformaities,organomegaly)
Arms & legs (S.C fat , muscles,wrists & nails)

6. Skin( Exposed and

covered,rash,desqumation)

Why we need to treat FTT as early as

possible?

1. Maximal postnatal brain growth occurs in the

first 6 mo of life, FTT early in life, regardless of
cause, is a serious illness.
2. FTT is associated with increased both morbidity
and mortality.
3. Early FTT is associated with increased risk
factors (including dyslipidemia, hypertension,
and glucose intolerance) for cardiovascular
disease as an adult (health and economic
issues).
4. FTT has a longterm emotional, cognitive and
metabolic effects (Developmental retardation ,
Learning difficulties).

Why we need to treat FTT as early as possible?

Endocrine System effects
Reduced levels of
A. T3.
B. Insulin.
C. insulin- like growth factor-1 (IGF-1).

Raised levels of

D. Growth hormone.
E. Cortisol .
Glucose
F. Initially low (depletion of glycogen stores).
G. Glucose intolerance of unclear aetiology.
H. Profound hypoglycaemia during the renourishment .

Why we need to treat FTT as early as possible?

Immune System effects

1. Cellular immunity defects:
A. Atrophy of the thymus, lymph nodes, and
tonsils.
B. Reduced CD4 but preserved CD8-T
lymphocytes.
C. Loss of delayed hypersensitivity.

2. Impaired phagocytosis,
3. Reduced secretory immunoglobulin A (IgA).
All increase risk of invasive infections.

Why we need to treat FTT as early as possible?

GIT System effects

A. Villous atrophy & crypt hypoplasia
(malabsorption).
B. Bacterial overgrowth (reduced gastric acid) .
C. Pancreatic atrophy (fat malabsorption).
D. Fatty infiltration of the liver is common but
synthetic functions are usually preserved.
E. Decreased protein synthesis, gluconeogenesis.
F. Decreased drug metabolism are.

Why we need to treat FTT as early as possible?

CNS effects
A. Reductions in the numbers of neurons,
synapses, dendritic arborization, and
myelinations, all of which result in decreased
brain size.

B. Delays in global function, motor function, and

memory loss, with neonates and infants being
most susceptible.

Why we need to treat FTT as early as possible?

Among the four principal causes of

mortality in young children worldwide,
under nutrition is the cause of death in

1.60 to 70 % of children with diarrheal

diseases.
2.52.3 % of those with pneumonia.
3.44.8%of measles cases.
4.57.3 % of children with malaria.

Macro & Micronutrient deficiency

nutritionally
inadequate foods
such as rice milk,
(low protein and
micronutrient
content)

A14mooldgirlwith
aflakypaintdermatitis.
Kwashiorkor (Rice
nightmare).