Child With Failure To Thrive Health And Social Care Essay

Child With Failure To Thrive Health And Social C be EssayIn this review article, the commentary, aetiology, military rank, differential diagnoses, management, prevention and prospect of let onure to thrive are discussed.Failure to thrive (FTT) is a cat valium problem in paediatric practice, affecting 5-10% of under-fives in developed countries with a high relative incidence in developing countries. Majority of cases of FTT are delinquent to a combination of nutritional and environmental deficiency secondary to agnatic poverty and/or ignorance. Many infants with FTT are not identified. The key to diagnosing FTT is finding the cartridge holder in busy clinical practice to accurately measure and plot a tykes weight, superlative degree and head border, and then assess the trend. In the evaluation of the nipper who has failed to thrive, common chord initial steps required to develop an economical treatment-centred nestle are (i) A thorough accounting including itemized psychosocial review, (ii) Careful physical psychometric test and (iii) Direct observation of the childs behaviour and of parent-child interaction. Laboratory evaluation should be guided by history and physical examination findings only. Once FTT is identified in a particular child, the management should begin with a careful search for its aetiology. Two principles that hold truthful irrespective of aetiology are that on the whole children with FTT need a high-calorie forage for catch-up exploitation (typically 150 share of their caloric requirement for their expected, not actual weight) and all children with FTT need a careful follow up. Social issues of the family must also be addressed. A multidisplinary approach is recommended when FTT persists despite intervention or when it is severe. Overall, only a third of children with FTT are ultimately judged to be pattern.Keywords Failure to thrive, suppuration deficiency, undernutrition.INTRODUCTIONAlthough the terminal failur e to thrive (FTT) has been in use in the medical set phrase for quite roughly time now, its precise definition has remained debatable1. consequently, different terms such(prenominal) as undernutrition1 and issue deficiency2 get been proposed as preferable. FTT is a descriptive term applied to young children physical branch is slight(prenominal) than that of his or her peers.3 The growth failure may begin either in the neonatal period or aft(prenominal) a period of normal physical development.4 The term FTT is not, in itself, a disease but a symptom or sign common to a wide variety of disorders which may have little in common except for their negative effect on growth.5 In this regard, a causal agency must always be sought. frequently, the evaluation of children who fail to thrive pose a difficult diagnostic problem. Some of the difficulties result from the numerous differential diagnoses, the definition used or misdirected tendency to search aggressively for underlying cons titutive(a) diseases while neglecting aetiologies found on environmental deprivation.6 In addition, early accusations and alienation of the childs parents by the health-care provider will make the evaluation and management of the child who has failed to thrive to a greater extent difficult.7In general, factors that influence a childs growth allow (i) A childs nutritional status (ii) A childs health (iii) Family issues and (iv) The parent-child interactions.3,8,9 All these factors must be considered in evaluation and management of child who has failed to thrive. This paper presents a simplified but detail approach to the evaluation and management of the child with FTT.DEFINITIONThe best definition for FTT is the one that refers to it as inadequate physical growth diagnosed by observation of growth over time exploitation a standard growth chart, such as the National Center for Health Statistics (NCHS) growth chart.10 All authorities accept that only by comparing bloom and weight on a growth chart over time can FTT be assessed accurately.11 So far, no consensus has been reached concerning the specific anthropometrical criteria to define FTT.11 Consequently, where sequential anthropometric records is not available, FTT has been variously defined statistically. For instance, nearly authors defined FTT as weight below the third percentile for age on the growth chart or more than two standard deviations below the mean for children of the same age and sex1-3 or a weight-for-age (weight-for-hieght) Z-score less than minus two.1 Others cite a downward change in growth that has crossed two major growth percentiles in a short time.3 silence others, for diagnostic purposes, defined FTT as a disproportionate failure to gain weight in comparison to height without an apparent aetiology.6 Brayden et al.,2 suggested that FTT should be considered if a child less than 6 months old has not grown for two consecutive months or a child older than 6 months has not grown for t hree consecutive months. Recent research has validated that the weight-for-age approach is the simplest and most creatorable marker of FTT.12Pitfalls of these definitionsOne limitation of using the third percentile for defining FTT is that some children whose weight fall below this arbitrary statistical standard of normal are not failing to thrive but represent the three percent of normal population whose weight is less than the third percentile.5,6 In the first 2 years of life, the childs weight changes to follow the genetic predisposition of the parents height and weight.13,14 During this time of transition, children with familial short stature may cross percentiles downward and still be considered normal.14 Most children in this category find their true curve by the age of 3 years.6,14 When the percentile drop is great, it is helpful to compare the childs weight percentile to height and head circumference percentiles. These should be consistent with the position of height and he ad circumference percentiles of the patient.5 Another limitation of the third percentile as a criterion to define FTT is that infants can be failing to thrive with marked deceleration of weight gain, but they remain undiagnosed and therefore, untreated until they have fallen below the arbitrary third percentile.6 These normal small children do not demonstrate the disproportionate failure to gain weight that children with FTT do.6 This approach attempts not only to prevent normal small children from being incorrectly labeled as failing to thrive, but also excludes children with pathologic proportionate short stature.14 Having excluded these easily distinguishable disorders from the differential diagnosing of FTT, simplifies the approach to evaluation of the child who has failed to thrive.6A more encompassing definition of FTT includes any child whose weight has fallen more than two standard deviations from a previous growth curve.3,15,16 Normal shifts in growth curves in the first 2 years of life will result in less severe decline (i.e, less than 2 SD).13Some authors have even limited the definition of FTT to only children less than 3 years old17,18 A precise age limitation is arbitrary. However, most children with FTT are under 3 years of age.6,8EPIDEMIOLOGYIn young children, FTT which does not reach the severe classical syndrome of marasmus is common in all societies.19 However, the true incidence of FTT is not known as galore(postnominal) infants with FTT are not identified, even in developed countries.20-22 It is estimated to affect 5 10% of young children and approximately 3 5% of children admitted into teaching hospitals.3,5,23 Mitchell et al,24 using multiple criteria found that nearly 10% of under-fives attending primary health care centre in the United States showed FTT. About 5% of paediatric admissions in United Kingdom are for FTT.4 The prevalence is even higher in developing countries with wide-spread poverty and high rates of malnutrition and/ or HIV transmissions.3,19 Children born to wiz teenage mystifys and working mothers who work for long hours are at increased risk.22 The same is true of children in institutions such as orphanage homes and homes for the mentally retarded5,22 with an estimated incidence of 15% as a group.5 Under- cater is the single commonest cause of FTT and results from parental poverty and/or ignorance.19,22,24 Ninety five percent of cases of FTT are due to not profuse pabulum being offered or taken.25 The peak incidence of FTT occurs in children between the age of 9 24 months with no significant sex difference.22 Majority of children who fail to thrive are less than 18 months old.3 The syndrome of FTT is uncommon after the age of 5 years.3,22AETIOLOGYTraditionally, causes of FTT have been classified as non- organic fertiliser and organic. However, some authors have verbalise that this terminology is misleading.27 They based their opinion on the fact that all cases of FTT are produced by in adequate food or undernutrition and in that context, is organically determined. In addition, the eminence based on organic and non-organic causes is no longer favoured because many cases of FTT are of mixed aetiologies.3Based on pathophysiology (the preferred classification), FTT may be classified into those due to (i) Inadequate caloric intake (ii) Inadequate absorption (iii) increase caloric requirement and (iv) Defective utilization of calories. This classification leads to a logical organization of the many conditions that cause or contribute to FTT.10Non organic (psychosocial) failure to thriveIn non-organic failure to thrive (NFTT), there is no known medical condition causation the poor growth. It is due to poverty, psychosocial problems in the family, enate deprivation, lack of knowledge and skill in infant nutrition among the care-givers5,11. Other risk factors include substance affront by parents, single parenthood, general immaturity of one or both parents, economic s tress and strain, temporary stresses such as family tragedies (accidents, illnesses, deaths) and marital disharmony.6,8,22 Weston et al,28 reported that 66% of mothers whose infants failed to thrive has a positive history of having been abused as children themselves, compared to 26% of controls from similar socioeconomic background. NFTT accounts for over 70% of cases of FTT.6 Of this number, approximately one-third is due to care-givers ignorance such as incorrect provide technique, improper preparation of formula or misconception of the infants nutritional needs,29 all of which are easily corrected. A close look at these risk factors for NFTT suggest that infants with growth failure may represent a flag for serious social and psychological problems in the family. For example, a depressed mother may not feed her infant adequately. The infant may, in turn, become withdrawn in response to mothers depression and feed less salubrious.10 Extreme parental attention, either neglect or h ypervigilance, can lead to FTT.10Organic failure to thriveIt occurs when there is a known underlying medical cause. Organic disorders make FTT are most commonly infections (e.g HIV infection, terbium, intestinal parasitosis), gastrointestinal (e.g., chronic diarrhoea, gastroesophageal reflux, pyloric stenosis) or neurologic (e.g., cerebral palsy, mental retardation) disorders.6,19,22 Others include genitourinary disorders (e.g., posterior urethral valve, renal tubular acidosis, chronic renal failure, UTI), congenital heart disease, and chromosomal anomalies.6,7 Together neurologic and gastrointestinal disorders account for 60 80% of all organic causes of under nutrition in developed countries.30 An important medical risk factor for under nutrition in childhood is wrong birth.1 Among preterm infants, those who are small for gestational age are particularly vulnerable since prenatal factors have already exerted deleterious effect on somatic growth.1 In societies where lead poisoni ng is common, it is a recognized risk factor for poor growth.5,31 Organic FTT virtually never presents with isolated growth failure, other signs and symptoms are largely evident with a detailed history and physical examination.32 Organic disorders accounts for less than 20% of cases of FTT.6Mixed failure to thriveIn mixed FTT, organic and non organic causes coexist. Those with organic disorders may also suffer from environmental deprivation. Likewise, those with severe undernutrition from non-organic FTT can develop organic medical problems.FTT with no specific aetiologyReview of the books on FTT indicate that in 12 32% of cases of children who have failed to thrive, no specific aetiology could be established.23,33-34Causes of failure to thriveA. Prenatal cases (i) Prematurity with its torsion (ii) Toxic exposure in utero such as alcohol, smoking, medications, infections (eg rubella, CMV) (iii) Intrauterine growth restriction from any cause (iv) Chromosomal abnormalities (eg Dow n syndrome, Turner syndrome) (v) Dysmorphogenic syndromes.B. Postnatal causes based on pathophysiologyA. Inadequate caloric intake which may result fromi. Under feedingIncorrect preparation of formula (e.g. too dilute, too concentrated).Behaviour problems affecting eating (e.g., childs spirit).Unsuitable feeding habits (e.g., uncooperative child)Poverty leading to food shortages.Child abuse and neglect.Mechanical feeding difficulties e.g., congenital anomalies (cleft lip/palate), oromotor dysfunction.Prolonged dyspnea of any causeB. Inadequate absorption which may be associated withMalabsorption syndromes e.g. Celiac disease, cystic fibrosis, cows milk protein allergy, giardiasis, food sensitivity/intoleranceVitamins and mineral deficiencies e.g., zinc, vitamins A and C deficiencies.Hepatobiliary diseases e.g., biliary atresia.Necrotizing enterocolitisShort gut syndrome.C. Increased Caloric requirement due toHyper thyroidismChronic/recurrent infections e.g., UTI, respiratory tract infection, tuberculosis, HIV infectionChronic anaemiasD. Defective Utilization of CaloriesInborn errors of metabolism e.g., galactosaemia, aminoacidopathies, organic acidurias and storage diseases.Diabetes inspidus/mellitusRenal tubular acidosisChronic hypoxaemiaClinical manifestations of FTT3,22Commonly the parents/care-givers may complain that the child is not growing well or losing weight or not feeding well or not doing well or not deal his other siblings/age mates. Usually FTT is discovered and diagnosed by the infants physician using the birthweight and health clinic anthropometric records of the child.The infant looks small for age. The child may exhibit vent of subcutaneous fat, reduced muscle mass, thin extremities, a narrow face, prominent ribs, and wasted buttocks, Evidence of neglected hygiene such as diaper rash, gross skin, overgrown and dirty fingernails or unwashed clothing. Other findings may include avoidance of eye contact, lack of facial expression, absence of cuddling response, hypotonia and presumptuousness of infantile posture with clenched fists. There may be marked preoccupation with thumb sucking.EVALUATIONA. Initial evaluationIt has been proposed that only three initial investigations are required to develop an economical, treatment-centred approach to the child who presents with FTT and this include35 (i) A thorough history including an itemized psychosocial review (ii) Careful physical examination including intent of the auxological parameters and (iii) Direct observation of the childs behaviour and of parent-child interactions.The Psychosocial Review The psychosocial history should be as thorough and systematic as a classic physical examination Goldbloom35 suggested that the interviewers should imply themselves three questions about every family (i) How do they look (ii) What do they say and (iii) What do they do?a. HISTORY(1) comestibleal historyNutritional history should includeDetails of breast feeding to get an idea of number of feeds, time for each feeding, whether both breasts are given or one breast, whether the feeding is act at night or not and how is the childs behaviour before, after and in between the feeds. It would give an idea of the adequacy or inadequacy of mothers milk. If the infant is on formula feeding Is the formula prepared correctly? Dilute milk feed will be poor in calorie with excess water. alike concentrated milk feed may be unpalatable leading to refusal to drink. It is also essential to know the occur quantity of the formula consumed. Is it given by bottle or cup and spoon? Also assess the feeling of the mother e.g., ask how do you feel when the baby does not feed well? Time of introduction of complementary feeds and any difficulty should be noted.Vitamin and mineral supplement when started, type, amount, duration.Solid food when started, types, how taken.Appetite whether the appetite is temporarily or persistently impaired (if necessary calculate the caloric intake).Fo r older children enquire about food likes and dislikes, allergies or idiosyncracies. Is the child fed forcibly? It is desirable to know the feeding routine from the time the child wakes up in the morning till he sleeps at night, so that one can get an idea of the total caloric intake and the calories supplied from protein, fat and carbohydrate as well as adequacy of vitamins and minerals intake.(2) Past and current medical historyThe history of prenatal care, maternal illness during pregnancy, identified fetal growth problems, prematurity and birth weight. Indicators of medical diseases such as vomiting, diarrhoea, fever, respiratory symptoms and fatigue should be noted. Past hospitalization, injuries, accidents to evaluate for child abuse and neglect. Stool pattern, frequency, consistency, presence of blood or mucus to exclude malabsorption syndromes, infection and allergy.(3) Family and social historyFamily and social history should include the number, ages and sex of siblings. r ealize age of parents (Down syndrome and Klinerfelter syndrome in children of elderly mothers) and the childs place in the family (pyloric stenosis). Family history should include growth parameters of siblings. Are there other siblings with FTT (e.g., genetic causes of FTT), family members with short stature (e.g. familial short stature). Social history should determine occupation of parents, income of the family, identify those caring for the child. Child factors (e.g., temperament, development), parental factors (e.g., depression, domestic violence, social isolation, mental retardation, substance abuse) and environmental and social factors (e.g., poverty, unemployment, illiteracy) all may contribute to growth failure.5 Historical evaluation of the child with FTT is summarized in Table 1.(b) PHYSICAL EXAMINATIONThe four main goals of physical examination include (i) identification of dysmorphic features suggestive of a genetic disorder impeding growth (ii) detection of under lying disease that may impair growth (iii) assessment for signs of possible child abuse and (iv) assessment of the severity and possible effects of malnutrition.36,37The basic growth parameters such as weight, height / length, head circumference and mid-upper-arm circumference must be measured carefully. Recumbent length is measured in children below 2 years of age because standing measurements can be as much as 2cm shorter.36,37 Other anthropometric data such as upper-segment-to-lower-segment ratio, sitting height and arm span should also be noted. The anthropometric index used for FTT should be weight-for-length or height. Mid-parental height (MPH) should be determined using the formula.40For boys, the formula isMPH = FH + (MH 13)2For girls, the formula isMPH = (FH 13) + MH2In both equations, FH is fathers height in centimetres and MH is mothers height in centimetres. The target range is calculated as the MPH 8.5cm, representing the two standard deviation (2SD) confidence limits.14 mind of degree FTTThe degree of FTT is usually measured by calculating each growth parameter (weight, height and weight/height ratio) as a parcel of the median value for age based on appropriate growth charts3 (See Table 3)Table 3 Assessment of degree of failure to thrive (FTT) result parameterDegree of Failure to ThriveMildModerateSevereWeight75-90%60 -74%Height90 -95%85 89%Weight/height ratio81-90%70 -80%Adapted from Baucher H.3It should be noted that appropriate growth charts are often not available for children with specific medical problems, therefore serial measurements are especially important for these children.3 For premature infants, correction must be made for the extent of prematurity. Corrected age, rather than chronologic age, should be used in calculations of their growth percentiles until 1-2 years of corrected age.3Table 2 Physical examination of infants and children with growth failure. kinkyityDiagnostic ConsiderationVital signsHypotensionHypertensionTachypnoea/ TachycardiaAdrenal or thyroid insufficiencyRenal diseasesIncreased metabolic demandSkinPallorPoor hygieneEcchymosesCandidiasisEczemaErythema nodosumAnaemaNeglectAbuseImmunodeficiency, HIV infection sensitized diseaseUlcerative colitis, vasculitisHEENTHair lossChronic otitis mediaCataractsAphthous stomatitisThyroid enlargementStressImmunodeficiency, structural oro- facial defectCongenital rubella syndrome, galactosaemiaCrohns diseaseHypothyroidism tittyWheezesCystic fibrosis, asthmaCardiovascularMurmurCongenital heart disease(CHD)AbdomenDistension hyperactive Bowel sound HepatosplenomegalyMalabsorptionLiver disease, glycogen storage diseaseGenitourinaryDiaper rashesDiarrhoea, neglectRectumEmpty ampullaHirschsprungs diseaseExtremitiesOedemaLoss of muscle mass ClubbingHypoalbuminaemiaChronic malnutritionChronic lung disease, Cyanotic CHDNervous systemAbnormal deep tendon Reflexesdevelopmental delayCranial nerve palsyCerebral palsyAltered caloric intake or requirementsDysphagiaBehaviour and temperamentUncooperativeDifficult to feed.Adapted from Collins et al 41Growth charts should be evaluated for pattern of FTT. If weight, height and head circumference are all less than what is expected for age, this may suggest an insult during intrauterine life or genetic/chromosomal factors.2 If weight and height are delayed with a normal head circumference, endocrinopathies or constitutional growth should be suspected.2 When only weight gain is delayed, this usually reflects recent energy (caloric) deprivation.2 Physical examination in infants and children with FTT is summarized in Table 2.Failure to thrive due to environmental deprivationChildren with environmental deprivation primarily demonstrate signs of failure to gain weight loss of fat, protuberance of ribs and muscles wasting, especially in large muscle groups such as the gluteals.6developmental assessmentIt is important to determine the childs developmental status at the time of diagnosis because children with FTT h ave a higher incidence of developmental delays than the general population.36 With environmental deprivation, all milestones are usually delayed once the infant reaches 4 months of age.42 Areas certified on environmental interactions such as language development and social adaptation are often disproportionately delayed. Specific behavioural evaluations (e.g., recording responses to approach and withdrawal), have been developed to help differentiate underlying environmental deprivation from organic disease.43 Assess the infants developmental status with a full Denver Developmental Standardized test.44Parent-child interactionEvaluate interaction of the parents and the child during the examination. In environmental deprivation, the parent often readily walks away from the examination table, appearing to easily fury the child to the nurse or physician.6 There is little eye contact between child and parent and the infant is held distantly with little moulding to the parents body.6 Oft en the infant will not reach out for the parent and little affectionate touching is noted.6 There is little parental display of pleasure towards the infant.6 expression of feeding is an integral part of the examination, but it is ideally done when the parents are least aware that they are being observed. Breast-fed infants should be weighed before and after several feedings over a 24-hour period since volume of milk consumed may vary with each meal. In environmental deprivation, the parents often miss the infants cues and may flurry him during feeding the infant may also turn away from food and appear distressed.6 Unnecessary force may be used during feeding. Developing a portrait of the child-parent relationship is a key to guiding intervention.11LABORATORY EVALUATIONThe role of testing ground studies in the evaluation of FTT is to investigate for possible organic diagnoses suggested by the history and physical examination.33,34 If an organic aetiology is suggested, appropriate s tudies should be undertaken. If history and physical examination do not suggest an organic aetiology, extensive laboratory test is not indicated.6 However, on admission full blood count, ESR, urinalysis, urine culture, urea and electrolyte (including calcium and phosphorus) levels should be carried out. Screen for infections such as HIV infection, tuberculosis and intestinal parasitosis. Skeletal survey is indicated if physical abuse is strongly suspected. In addition to being unproductive, blind laboratory fishing expeditions should be avoided for the following reason5,6 (i) they are expensive (ii) they impair the childs ability to gain weight in a new environment both by frightening him/her with venepuncture, barium studies and other stressful procedures and the no oral feeds associated with some investigations prevent him/her from getting enough calories (iii) they can be misleading since a number of laboratory abnormalities are associated with psychosocial deprivation (e.g., inc reased serum transaminases , transient abnormalities of glucose tolerance, decreased growth hormone and iron deficiency)21 and (iv) they divert attention and resources from the more productive search for evidence of psychosocial deprivation. In one study, a total of 2,607 laboratory studies were performed, with an average of 14 tests per patient. With all tests considered, only 10(0.4%) served to establish a diagnosis and an additional 1% were able to donjon a diagnosis.34Further Evaluation(1) Hospitalization Although some authors state that most children with failure to thrive can be treated as outpatients,4,5,11,45 I turn over it is best to hospitalize the infant with FTT for 10 14 days. Hospitalization has both diagnostic and therapeutic benefits. Diagnostic benefits of admission may include observation for feeding, parental-child interaction, and reference of sub-specialists. Therapeutic benefits include administration of intravenous fluids for dehydration, systemic antibiot ic for infection, blood transfusion for anaemia and possibly, parenteral nutrition, all of which are often in-hospital procedures. In addition, if an organic aetiology is discovered for the FTT, specific therapy can be initiated during hospitalization. In psychosocial FTT, hospitalization provides opportunity to educate parents about appropriate foods and feeding styles for infants. Hospitalization is necessary when the rubber of the child is a concern. In most situations in our set up, there is no viable alternative to hospitalization.(2) Quantitative assessment of intake A future 3-day diet record should be a standard part of the evaluation. This is useful in assessing under nutrition even when organic disease is present. A 24-hour food recall is also desirable. Having parents write down the types of food and amounts a child eats over a three-day is one way of quantifying caloric intake. In some instances, it can make parents aware of how much the child is or is not eating.11Tab le 4 Summary of risk factors for the development of failure to thrivebaby characteristicsAny chronic medical condition resulting in Inadequate intake (e.g, swallowing dysfunction, central nervous systemdepression, or any condition resulting in anorexia) Increased metabolic rate (e.g, bronchopulmonary dysplasia, congenital heartdisease, fevers) Maldigestion or malabsorption (e.g, AIDS, cystic fibrosis, short gut,inflammatory bowel disease, celiac disease). Infections (e.g., HIV, TB, Giardiasis)Premature birth (especially with intrauterine growth restriction)Developmental delayCongenital anomaliesIntrauterine toxin exposure (e.g. alcohol)Plumbism and/or anaemiaFamily characteristicsPovertyUnusual health and nutrition beliefsSocial isolationDisordered feeding techniquesSubstance abuse or other psychopathology (include Muschausen syndrome by proxy)Violence or abuseAdapted from Kleinman RE.1Table 1 Summary of historical evaluation of infants and children with growth failurePrenatalGenera l obstetrical historyRecurrent miscarriagesWas the pregnancy planned?Use of medications, drugs, or cigarettesLabour, delivery, and neonatal eventsNeonatal asphyxia or Apgar scoresPrematuritySmall for gestational ageBirth weight and lengthCongenital malformations or infectionsMaternal bonding at birth length of hospitalizationBreastfeeding supportFeeding difficulties during neonatal periodMedical history of childRegular physicianImmunizationsDevelopmentMedical or surgical illnesses patronize infectionsGrowth historyPlot previous pointsNutrition historyFeeding behavior and environmentPerceived sensitivities or allergies to foodsQuantitative assessment of intake (3-day diet record, 24-hour food recall)Social historyAge and occupation of parentsWho feeds the child?Life stresses (loss of job, divorce, death in family)Availability of social and economic support (Special Supplemental Nutrition Program forWomen, Infants and Children Aid for Families with Dependent Chi