Nutrition and Failure to Thrive

Question 1

What is the normal baby birth weight? Normal weight gain?

Answer 1

• 3.1-3.3kg
• biggest teratogen is smoking - 10g of birth weight per cigarette 30/d = decrease by 300g
• placenta perfusion

too small got risk, too big got risk

Normal weight gain

• 0-3 months 150-200g/week
• 3-6 months 100-150g/week
• 6-12 months 70-90g/week

very fast - 12cm a year in adolescence next fastest.

Question 2

Talk through some types of formulas and the differences?

Answer 2

• Breast milk
• Standard term formula (Cow’s milk based)
• Soy (Infasoy)
• Hydrolyzed formulas (peptide)
• Amino acid formulas (e.g. Neocate, Elecare)

Question 3

What are the prinicples of Solid food feeding?

Answer 3

• 4-6 months
• start a new food every third day
• meats at 7 months (chewing reflex at 7-9 months)
• avoid bottle feeding beyond 18. - rot teeth, eustachian tube function.

Question 4

Definition of Failure to thrive.

Answer 4

• arbitrary definition - implies failure to gain weight with height + head circumference.
• head circumference generally well preserved, indicator of brain growth.
  
  • pattern of growth
• catch-down growth = small baby reaching their genetic potential.
  
  • family growth parameters
  • triceps skinfold thickness

Question 5

List some causes of Failure to thrive? How do you classify it?

Answer 5

• Categorise based on Prenatal, Postnatal, switch to solids or organ systems:
  
  • Prenatal
    
    • prematurity
    • maternal malnutrition
    • toxic exposure
      
      • alcohol
      • smoking
      • meds
      • infection
    • IUGR
    • chromosomal
  • Postnatal
    
    • Poor absorption
      
      • pancreas
      • inborn error of metabolism
      • GI anomaly
    • Inadequate intake
      
      • suck/swallow difficulties
      • vomiting reflex
      • lack of appetite
    • increased metabolic demand
      
      • inflammatory disease
      • HIV
      • malignancy
      • renal failure
      • thyroid
    • Other (non-organic)
      
      • Meadow syndrome (emotional FTT)
  • Switch to solids
    
    • coeliacs (most common)
    • cows milk allergy (in breastfed)

Question 6

How do you take a FTT history?

Answer 6

• Intake
  
  • what is consumed
  • how is it made up
  • when were solids added
• Output
  
  • amount and colour of vomit
  • stool frequency and consistency
• Birth
  
  • weight
  • gestation
  • complications
• Past history
  
  • chronic illness
  • recurrent infections
• Family history
  
  • possible maternal depression
  • growth pattern of family
  • illnesses
  • consanguinity
• Development
  
  • plot all growth parameters

Question 7

Differentiate between macronutrients and micronutrients? Why is it important to differentiate?

Answer 7

• its important to differentiate as someone who is overfed can still have micronutrient difficiencies?

Question 8

Epidemiology of Obese children? What is the definition?

Answer 8

• 1/4 all Australian youths 1.8million
• signification long term

BMI cut off charts define it: changes for age/gender

• >85% = overweight
• >95% = obese (very overweight as pajoritive)

RFs:

• ethnicity
• sleep duration
• urbanisation
• reduced breastfeeding (formular fed have increased growth during infancy)
• screen time
• maternal obesity
• socioeconomic

Question 9

What do you do for an overweight child? When do you refer?

Answer 9

Hx/Ex:

• puberty
• height and weight
• BP, sleep, DM, CVD

SMART (specific, measurable, attainable, relevant, timebound) Goals

Lifestyle change (pre-contemplation, preparation, action)

5Es:

• empathise
• evaluate
• explore
• educate
• empower

More of veggies - 1/4 carb 1/4 meat, physical activity (2 hour or less TV/screen) , sleep

When to refer:

• height below 10th centile and unexpectedly short
• precocious puberty
• severe obesity <2
• symptoms of genetic/endocrine disease
• associated morbidity
• disordered eating (psych)

Question 10

What is the difference between failure to thrive and short stature? Define the two

Answer 10

• Failure to thrive:
  
  • underlying deficiency suggested
  • height centile exceeds weight = thing (lower BMI)
• Short stature:
  
  • endocrine and skeletal abnormalities
  • weight centile exceeds that of height (chubby)

Question 11

What is used to assess growth?

Answer 11

• Weight
  
  • standiometer
  • accurate digital scales
• Height
  
  • average of parents -6.5 for girls and +6.5 for boys
• timing of parental puberty development (inherent trait)
• Orchidometer
  
  • 1-3mls prepubertal
  • 4-15mls pubertal
  • 20-25mls adult
• BMI
• bone age (left wrist XR assessment)
  
  • Gruelich and Pyle radiographic bone atlas

Question 12

Outline hormonal influences of growth, talk through some of the physiology of growth.

Answer 12

• Condroblasts stimulated by GH
• hypertrophic zone stimulated by IGF1
• osteblasts by TH
• oestrogen invades the cartilaenous growth plates
• glucocorticoids inhibit chondroblast maturation

Question 13

What hormones can you measure in a child with short stature?

Answer 13

• IGF1 - correlates to bone growth hormone status and nutriti
• IGFBP3 - production is stimulated by growth hormone
• Free T4 and TSH for short stature - panhypothyroidism (can have normal TSH but low T4 so do both)
• Renal U&Es,
• lFT

Question 14

What are some first line investigations in FTT where there is concern but no specific medical clues?

Answer 14

• FBE/ESR
• UEC
• LFT
• Iron studies
• CMP
• TFT
• blood glucose
• MSU/MCS
• coeliac screen
• stool microscopy and culture
• stool for fat globules and fatty acid crystals
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