Failure to thrive 

This is a video on failure to thrive, including how it's defined, assessed, as well as causes of failure to thrive.
This video was made using Google Slides.
All images were created or adapted from Wikipedia Commons.
ADDITIONAL TAGS:
FAILURE TO THRIVE
Definition: Pediatric patient with failure to gain weight or inappropriate loss of weight.
Pathophysiology
Nutritional intake does not support normal growth and development. This can be because of
inadequate calorie intake;
malabsorption (calories are going into the gut but not making it into the blood/body); and/or
increased metabolic demand
Diagnose
Plot growth curves for height, weight, head circumference
Drop off of growth curve (falling below =2 centile spaces [parallel lines]) and wt for age (or wt for ht) below 3rd %ile are concerning
In FTT, weight drops first, then height, then head
Weight loss is normal after birth, but babies should lose =10% of their birth weight and regain within 3 weeks
Interview. Ask about:
Feeds: How frequent? How much? How do they mix formulas?
Stools: How frequent? How much? Consistency, color...
Rule out abuse. Look out for:
Suspicious wounds, bruises (in various locations, diff stages of healing, not consistent with story)
Circular burns (cigarette), water dunk burns (feet, ankles, butt only)
Running from caregiver, fear of caregiver
Differential diagnosis (next)
Inadequate caloric intake
Inadequate food supply: #1 etiology globally; caused by poverty or poor understanding of feeding; insufficient food supply from bottle or breast
Postpartum depression/maternal depression: mothers with postpartum depression are at increased risk for experiencing breastfeeding difficulties
Child neglect: #1 cause in USA (5-10%);
Cleft lip and cleft palate: uni- or bilateral; hard and/or soft palate; apparent on exam; impaired oral motor coordination → poor suck and poor swallow; repair lips at 10-12 weeks, palate 10-12 months, or risk speech/feeding/hearing problems and otitis media
Gastroesophageal reflux disease: sx- irritability, fussiness, and spitting up after feeds; pathophys is short esophagus, partial LES closure, lying supine; tx- smaller feeds, tummy time after meals; resolves by 1-2 yo
Malrotation: (of intestines during development); dx- x-ray, u/s might show GI tract cutoff; predispose to volvulus (gut twisting around mesenteric blood supply) → n/v, abd pain, distension, large dilated loop on x-ray; tx-corrective surgery
Pyloric stenosis: usually boys, 2-8 wks; forceful, projectile vomiting immediately after feeds; ex- olive-shaped mass, peristaltic waves; dx- low K, low Cl, metabolic alkalosis, donut sign on u/s; tx- IV fluids and surgery
Cerebral palsy/hypotonia
Avoidant/restrictive food intake disorder (ARFID)
Malabsorption/caloric retention defect
Food protein induced proctocolitis: non-IgE mediated allergy, 2-3%; sx: fussy after feeds, vomiting, bloody stool with cow’s milk (+/- soy); switch to hydrolyzed formula; try again at 2-3 yo
Celiac disease Short bowel syndrome: necrotizing enterocolitis is the most common cause.
Cystic fibrosis: AR mutation of CFTR; meconium ileus (FTPM); dx: newborn screen, or salty taste → sweat Cl test ( 40 infants, 60 peds); malnourished → supplement pancreatic digestive enzymes and DEAK vitamins; repeated resp infxns (pulm toilet, tx pseudomonas); infertility in men; kyphoscoliosis; digital clubbing
Biliary atresia: sx- FTT + jaundice, acholic stools; dx-high direct bili, u/s showing no ducts; tx- surgery to salvage liver (Kasai procedure)
Increased metabolic demand
Hyperthyroidism: FTT + bulging eyes, tachycardia, irritability vs Hypothyroid: constipation, poor feeding (not eager)
Chronic infections: tuberculosis, HIV, CVID, SCID
TORCH infections: congenital infxns that cause FTT + HSM, anemia, jaundice, chorioretinitis, purpura;
Toxoplasmosis- parasite from cat poop, raw meat, soil → brain Ca, hearing/vision loss, seizures;
Other (syphilis) →palms/soles rash, saber shins, saddle nose, Hutchinson’s teeth, dx-VDRL, RPR, then dark field or FTA ABS; tx-penicillin
Rubella → purpura- ‘blueberry muffin’ baby; cataracts; deafness; heart defects; tx-supportive
Cytomegalovirus → periventricular Ca; dx-urine, saliva → viral titers, PCR
Herpes → painful, burning vesicles on erythematous base (dew drops on rose petal); dx- PCR; tx- acyclovir
Inflammatory bowel disease: ulcerative colitis vs Crohn’s
Diabetes mellitus (FTT + polyuria, polyphagia, polydipsia)
Congenital heart defects: pansystolic murmur → echo → VSD → right hypertrophy (Eisenmenger syndrome); sx: enlarged liver, respiratory distress
Chronic lung disease: bronchopulmonary dysplasia, bronchiectasis
Inborn errors of metabolism: galactosemia (FTT+bilateral cataracts, jaundice), glycogen storage diseases (FTT+HSM, cirrhosis)