Session 22: Approach To Paediatric Endocrine Problems

Question 1

Failure to thrive

Answer 1

• Common problem of varying etiologies
• Usually within the first 1-2 years of life but may present at any time in childhood
• Associated with adverse effects on later growth, behaviour and cognitive development
• Important to differentiate FTT from normal variants of growth
• Various definitions but most refer to weight being <3rd centile / dropping 2 major percentile lines over time
• Generally describe a child whose weight or rate of weight gain is significantly below that expected of
  similar children of same sex, age and ethnicity
• Linear growth + head circumference often not affected or are affected to a lesser degree than weight

Normal weight gain (SpC Paed):
- Double by 4 months
- Triple by 9 months

Question 2

Failure to thrive vs Normal variants of growth

Answer 2

Normal variants of growth:
1. Infants with small parents that are growing to their genetic potential
- Birth weight: Low - Normal
- Parental percentile: Low
- Progress along percentile: Low percentile but does not cross percentiles

2. Infants with constitutional delay in growth
   - Birth weight: Low - Normal
   - Parental percentile: Normal
   - Progress along percentile: May be initial fall in first 6 months and then follow percentiles
3. Infants born prematurely who are growing below their age-matched peers
   - Birth weight: Normal if corrected for gestation
   - Parental percentile: Normal
   - Progress along percentile: Low if uncorrected but follow percentile curves, may show catch-up to normal range
4. Infants with postnatal “catch-down” growth
   - Birth weight: Large for date
   - Parental percentile: Normal
   - Progress along percentile: Initial fall in 6-12 months and then follow percentiles

Question 3

Causes of Failure to thrive

Answer 3

1. Inadequate caloric intake
   - Lack of appetite: chronic illness, psychosocial disorder
   - Food not available: neglect, feeding technique, disturbed parental-infant relationship
2. Inadequate absorption
   - Pancreatic insufficiency: cystic fibrosis
   - Damage to villous surface: celiac disease, cow’s milk protein allergy, necrotising enterocolitis (NEC) / short-gut syndrome
3. Excessive loss of nutrients
   - Vomiting: GERD, metabolic disorders, CNS disorders, drugs
   - Malabsorption / Diarrhoea: IBD, coeliac disease, allergic colitis
   - Renal loss: renal failure / renal tubular acidosis (RTA), diabetes mellitus, diabetes insipidus
4. Defective utilization of ingested nutrients
   - Chromosomal / Genetic abnormality
   - Metabolic disorders
5. Excessive utilization of energy
   - Chronic illness: cardiac disease, liver failure, renal failure, endocrine disorders, infections, anaemia

Question 4

History taking of Failure to thrive

Answer 4

1. Dietary history
   - Diet pattern: types of food and amount
   - Quantify caloric intake: three-day food diary
2. Feeding history
   - When, where, with whom
   - Feeding battles
   - Snack intake
3. Past + Current medical history
   - Birth history, complications, prematurity, SGA
   - Acute / Chronic illness, accidents, injuries
   - Vomiting, reflux, GI symptoms
   - Stool pattern: frequency, consistency, blood or mucus
4. Family history
   - Differentiate between falling to expected height and true FTT
   - Short stature, FTT, mental illness, other medical conditions
5. Social history
   - Family composition
   - Caregiver
   - Important stressors
   - Child neglect

Question 5

Physical examination of Failure to thrive

Answer 5

1. Dysmorphic features
   - suggestive of a genetic / chromosomal disorder
2. Underlying medical illness impairing growth
3. Sign of possible abuse
4. Severity and possible effects of malnutrition

Question 6

Investigations of Failure to thrive

Answer 6

Guided by History + P/E:
1. Blood tests
- CBP
- ESR
- LRFT
- Bone profile
- Blood glucose
- TFT
- Iron studies
- Immunoglobulin
- Celiac screen if Caucasian

2. Stool sample
   - Stool microscopy + culture
   - Fat globules, fatty acid crystals
3. Urine sample
   - Urine microscopy + culture
4. Other tests if clinically indicated
   - Metabolic screen: Plasma amino acids, Urine for organic acids
   - Karyotype
   - Allergy investigations: RAST, skin prick test
   - Sweat test (if suspect Cystic fibrosis)
   - OGD, colonoscopy

Question 7

Management of Failure to thrive

Answer 7

1. Correct underlying cause if identified
2. Multidisciplinary approach
   - referral to social worker /
   clinical psychologists if issues of attachment and other psychosocial issues identified
3. Nutritional intervention
   - referral to dietitian
   - high-calorie diet for catchup growth
   - 150% recommended daily caloric intake based on their expected, rather than actual, body weight
   - multivitamin supplements
4. Feeding behaviour modification
   - referral to occupational / speech therapy
5. Close follow-up for progress and possible later sequelae