Neonates + young years Flashcards
Define: failure to thrive
children <5 yo who have poor weight gain
weight
what is essential when assessing for FTT?
Must measure weight (bare), lenght ( height if > 2 yo) + head circumference
→ plot on centile chart
– REALITY check: are centiles congruent w child’s appearance?
– previous measurements + plot them
– is this growth/weight gain normal or abnormal?
What is normal?
0 to 3 months: 150 - 180g/wk (not a straight line - trend over time is important)
- double baby’s birthweight in 1st 3 months
3 to 6mo: 120g/wk
6-9 mo: 80g/wk
9-12 mo: 70g/wk
size at birth (esp weight) determined by uterine environment, size at 2yo determined by genes
NB:
“ catch up” growth for IUGR or SGA
eg: <3 centile at birth → p50 by 12mo
“catch down” growth
eg: LGA or infants of diabetic mums
p97 at birth, 50 at 12 mo
= NORMAL
familial pattern of growth
FFT incidence + RF
5-10% in primary care 3-5% in hospital
most (~80%) present before 18 mo
RF
- poor socioeconomic status
- poor knowledge of infant/child nutrition
- parental mental health issues
- young mother
- a/w child abuse - 4 x more likely
FTT causes - general approach + specifics
Organic vs non-organic
NB: most FFT is non-organic!
Initial approach
- Energy in → insufficient caloric intake
- Energy out → excessive loss of calories
eg: malabsorption or vomit - increased energy utilisation
eg: chronic disease such as CHD
1) INSUFFICIENT CALORIC INTAKE
- inadequate milk/food provided
- issues w breastmilk supply or formula
- poor feeding/swallowing due to structural cause eg: cleft palate
- lack of parental knowledge re: infant feeding + weight gain
- parental MH issue
- parental non-orthodox health beliefs + practices
- poverty (can’t afford appropriate formula etc)
2) EXCESSIVE LOSS OF CALORIES
excessive vomiting (a non-spec sign in infants)
- GIT: GORD, pyloric stenosis ( in first weeks of life, becoming more forceful then projectile)
- non-GIT: CNS, metabolic
malabsorption/excessive stool loses
eg: coeliac, CF, chronic liver disease, giardia
3) EXCESSIVE CALORIC UTILISATION
- congenital heart disease
- recurrent UTIs
- thyroid disease
- chronic lung disease eg: former preterm bub
- immunodeficiency
- recurrent infection
- metabolic disorders
FTT: approach to Hx
HISTORY (gives 75% of Dx)
Caloric intake - get specific + detailed facts
- quantity of solids vs liquids/milk
- 30ml milk = 20 cal
- need 150ml/kg/day milk
- parental knowledge + recall of diet
- consider watching a feed + prep of formular
Observe mother-children interaction
- warmth, sensitivity, responsiveness
PMHx (illnesses, seen other doctors/hospitals/tests?) Complete pregnancy + perinatal Hx ? documentation of this Developmental Hx FHx - parent/sibling height + weights, relatives SHx finances + supports parental MH, D+A unconventional beliefs re: infant care previous DHHS/child protection Hx
meds
seen any C+A practitioners?
FFT examination
most valuable diagnostic test
Well/unwell → consider immediate referral
Dysmorphic?
centiles - progressive?
→ if short w appropriate weight → endocrine cause??
NB: weight impacted earliest + most, then slow linear length is next after longer term FTT, head growth not effected except in extreme circumstances
– small head size usually points to another issue eg: microcephaly, genetic syndrome, neurological disorder, craniostenosis
muscle bulk in thighs, buttocks
other signs of malabsorption/nutrient deficiency
other illnesses
- cardiac
- renal
- neurodevelopmental
Ix to consider for FTT
pick up rate 1-2%
Bloods
- UEC/LFT/ BSL/ CMP
- FBE, iron studies, B12, folate, coags
- TTG Abs, total IgA (coeliac)
- TFTs
urine MCS ? metabolic scren
stool MCS, OCP, fat globules
consider chekcing newborn screening test ? done ? normal?
other test (genetic, metabolic, imaging) on clinical grounds
consider admission to hospital
- observe + document feeding + weight gain
- observe mother-child interaction
- MDT - AH involvement
- consider 2nd opinion
- if no answer, reconsider psychosocial issues + possibility of abuse/neglect
Mx non-organic FTT
ensure weight gain - may take 1-2 weeks assess mother child interaction MDT conference home or foster care (may need court) long term FU
fixing shortterm refeeding is easy
- be aware, not paranoid, crazy parents ‘alternative’ w weird beliefs, a/w FFT + child abuse
long term effects on growth, small risk neurodevelopmental issue (AS brain development is the greatest in the 1st year of life → can lead to DD if not Mx)
Non-FTT concerns re: growth
“doesnt eat anything” - normal growth
milkaholism ( beware of iron deficiency)
meal times as battleground
statistics - 3% can be normal!
Indications for F/U of infant with weight loss
infants from 2 weeks to 3 months
- often lose weght in first few days and regain birth weight by 1 week
- should be gaining 150g/week
- if fail to do so → NEED evaluation
Other indications
- failure to regain birthweight by 2 weeks age
- loss of >10% birth weight in 1st 2 weeks of life
- lack of UO in 24hr period, or clinical signs of dehydration
NB: breastfed infants will show more variations in growth + growth typically decelerates
non-pathological causes low centile
variation of normal -specifically if child has no features of wasting, weight is appropriate for height, appears healthy
child may be following genetic potential (measure MID PARENTAL HEIGHT)
child may have been preterm or low birth weight → catch up growth continues into:
- 2nd year for weight
- 3rd year for height
– may continue up to the school years
NB: breastfed generally have slowing go growth from 3 - 12 months, although rarely cross 2 centile lines
options for poor supply
admit to mother craft facility
domperidone
