Pediatric Malnutrition: Under- and Over-weight in Children

Daniel Jackson, MD University of Utah School of Medicine 2012 Undernutrition: Global and Local

Famine •Political Instability •Distribution of Resources •Social Chaos •Survival/Recovery Nutrient Deficiency

Maternal-Child Dyad •Maternal Nutrition/Health •Intrauterine Onset •Nursing insufficiency •Weaning/transition Malabsorption

•Environmental Factors •Infection: parasitosis •MalabsorptionÆreduced intake •InflammationÆincreased energy needs Kwashiorkor

Displaced from nursing Low protein alternatives Endemic Infection GI protein loss HypoalbuminemiaÆEdema Marasmus

Protein-Calorie Undernutrition Fat and Muscle depletion Preserved plasma proteins Preserved homeostasis Failure to Thrive: Our world

Genetics Prenatal environment Behavioral factors Psychosocial context Disease factors To Thrive

„ HomeostasisHomeostasis „ FullFull physiologicphysiologic functionfunction „ WeightWeight gaingain „ LinearLinear growthgrowth „ CranialCranial growthgrowth „ NeurodevelopmentNeurodevelopment „ SocialSocial integrationintegration Navigating The Growth Curve

„ ExpectationsExpectations „ DeviationsDeviations „ RecoveryRecovery „ FalteringFaltering „ AcuteAcute wastingwasting „ ChronicChronic stuntingstunting „ CranialCranial stasisstasis CDC Growth Curves: 0-36 months CDC Growth Curves: 2-20 years Body Mass Index: kg/m2 Body Mass Index [BMI]: 2 years to 20 years BMI = weight (kg) / height2 (m2)

Extremely Obese: BMI >99th %ile

95 Obese: BMI 95th to <99th %ile 90 85 Overweight: BMI 85th to <95th %ile 75 50 25 10 5

Centers for Disease Control and Prevention Determination of % weight for height age:

Actual Wt: 7 kg Expected Wt: 8.4 kg 7/8.4 = 0.83 or 83% Hazards Around the Curve

„ InadequateInadequate nutrientnutrient intakeintake „ MaldigestionMaldigestion „ MalabsorptionMalabsorption „ Gut/RenalGut/Renal losseslosses „ MetabolicMetabolic demandsdemands „ CardiopulmonaryCardiopulmonary diseasedisease „ EndocrinopathyEndocrinopathy „ NeuropathologyNeuropathology „ PsychosociopathologyPsychosociopathology Genetic/Congenital

„ Dysmorphic/chromosomalDysmorphic/chromosomal syndromessyndromes

‹ DownDown’’s,s, TurnerTurner’’s,s, NoonanNoonan’’s,s, PraderPrader--WilliWilli „ MutationsMutations „ Parental/siblingParental/sibling growthgrowth patternpattern „ ConstitutionalConstitutional delaydelay „ FamilialFamilial shortshort staturestature „ IntrauterineIntrauterine growthgrowth retardationretardation Patterns of Failure to Thrive

„ NutritionalNutritional

‹ WeightWeight << LengthLength << HeadHead „ EndocrineEndocrine

‹ LengthLength << WeightWeight << HeadHead „ NeurologicNeurologic

‹ HeadHead << WeightWeight << LengthLength Nutritional Pattern Nutritional Pattern: DDx

„ InadequateInadequate NetNet IntakeIntake ‹ Deprivation ‹ Aversion, Dysphagia ‹ Vomiting/Reflux „ Maldigestion/MalabsorptionMaldigestion/Malabsorption ‹ Pancreatic Insufficiency: Cystic Fibrosis, Shwachman ‹ Mucosal disease: Giardia/Cryptosporidia; viral enteritis; Celiac disease „ IncreasedIncreased MetabolicMetabolic RequirementsRequirements ‹ Inflammation ‹ Cardiopulmonary disease Endocrine Pattern Short Stature: Patterns

Constitutional vs. Familial

GH deficiency Endocrine Pattern: DDx

„ HypothyroidismHypothyroidism

‹ Low Thyroxine (Free T4), High TSH „ GrowthGrowth HormoneHormone deficiencydeficiency

‹ Low Insulin like growth factor (IGF-1)

 Unreliable in undernutrition states

‹ Low IGF Binding Protein 3 (IGFBP3) „ HypopituitarismHypopituitarism

‹ Low cortisol, TSH, glucose, gonadotropins Neurogenic Pattern

macrocephalic

microcephalic Neurogenic Pattern: DDx

„ MicrocephalicMicrocephalic ‹ Infarction ‹ CMV viral infection ‹ Embryogenic defect:  neuronal migration ‹ Rett syndrome „ MacrocephalicMacrocephalic ‹ Hydrocephalus ‹ Tumor  Brainstem: Diencephalic syndrome ‹ Metabolic storage disease ‹ Autism

Rett Syndrome

Autism

Diencephalic Syndrome FTT: Definition

„ StaticStatic Criteria:Criteria: th ‹ Weight for Height < 5 %ile ‹ Weight < 85% median weight for height th ‹ Triceps skinfold thickness < 5 mm or < 5 %ile „ DynamicDynamic Criteria:Criteria: ‹ Subnormal growth velocity:  <20 g/d @ 0-3 months  <15 g/d @ 3-6 months ‹ Drop of 2 major centiles Diagnostic Approach

„ Prenatal/PerinatalPrenatal/Perinatal medicalmedical historyhistory „ HistoryHistory ofof medical/surgicalmedical/surgical illnessillness „ DietDiet historyhistory

‹ Weaning, Food introduction

‹ Meal Structure: intervals, schedule „ FamilyFamily HistoryHistory „ PhysicalPhysical ExaminationExamination „ StrategicStrategic laboratorieslaboratories andand RadiologyRadiology Diagnostic Evaluation

„ History: ‹ Maternal Health ‹ GA, BW, Perinatal, Infancy, Development, Medical and Surgical illness, interventions ‹ Link events to growth history: map on curve ‹ Feeding history  Nursing/weaning  Sequence of foods: introduction of solids  Frequency of feeding  Coercive feeding  Parental/infant feeding transactions/communication ‹ Psychosocial Problems Diagnostic Evaluation

„ PhysicalPhysical Examination:Examination: ‹ Measurements ‹ Hygiene ‹ Dysmorphisms: craniofacial, skeletal,etc. ‹ Epithelial integrity: skin, hair, nails, eyes, mucosa  Edema  Micronutrient deficiency ‹ Body composition: fat and muscle stores ‹ Cardiorespiratory status ‹ Neurodevelopmental status  Dysphagia ‹ Functional status: tone, responses, strength ‹ Child-Parent and Child-Examiner interactions Digital Clubbing Digital Clubbing

Cystic Fibrosis Celiac Sprue Cyanotic Heart Disease Cirrhosis Crohn Disease COPD Candidiasis Mucocutaneous Congenital

Acrodermatitis enteropathica Zinc deficiency

Noonan Turner

Fetal Alcohol

Williams Acute vs Chronic

„ AcuteAcute UndernutritionUndernutrition---- ““wastingwasting””::

‹ Low weight for height or low BMI

‹ “wasting” of fat and muscle mass

‹ Prelude to stunting

‹ Constitutional leanness „ ChronicChronic UndernutritionUndernutrition–– ““stuntingstunting””::

‹ Low height for age

‹ Normalized weight for height and BMI

 Consider constitutional growth delay

 Consider Endocrinopathy: hypothyroidism, hypopituitarism Cranial growth

„ ReflectsReflects brainbrain growth/volumegrowth/volume „ BrainBrain majormajor metabolicmetabolic demanddemand inin infantsinfants „ RelativelyRelatively preservedpreserved inin undernutritionundernutrition

‹ EarlyEarly infancy:infancy: maymay followfollow weightweight decelerationdeceleration

‹ LowLow relativerelative toto Length:Length:

 1° neurologic etiology

 Intrauterine Insult

 Metabolic Composition of Metabolic Demand TDEE = [1.4 to1.6] x BMR %BMR / 1.5 = % TDEE 60% BMR = 45 % TDEE 40% BMR= 27 % TDEE

HOLLIDAY, M.A.: Body composition and energy needs during growth. In: Human Growth: A Comprehensive Treatise, 2nd ea., pp. 101-117, F. FALKNER, J.M. TANNER (Eds.), Plenum Press, New York, NY, 1986. 7 month male with early growth arrest attributed to nursing insufficiency, followed by recovery. His growth worsened after 5 months age when solids were introduced, despite parental efforts to feed him every 1-2 hours. .

Laboratory

„ DirectedDirected byby History,History, ValidatedValidated byby Exam,Exam, ConditionedConditioned byby ExperienceExperience „ Otherwise:Otherwise: reservereserve forfor failurefailure toto respondrespond toto nutritional/behavioral/environmentalnutritional/behavioral/environmental interventionintervention „ CBC/smear,CBC/smear, Urinalysis,Urinalysis, SweatSweat Chloride,Chloride, CeliacCeliac serology,serology, StoolStool parasites,parasites, FEPFEP--Pb,Pb, quantitativequantitative IgA,IgA, ElectrolytesElectrolytes--BUNBUN--Creatinine,Creatinine, zinc/alkalinezinc/alkaline phosphatase,phosphatase, TSHTSH Problem with Disease Model: -the hospital FTT workup

„ ImprobableImprobable oror BassBass--ackwards:ackwards: ‹ Minority with discernable relevant pathology „ ExpensiveExpensive „ DistractionDistraction ofof medicalizationmedicalization „ MorbidityMorbidity ofof testingtesting „ HospitalHospital artifactartifact ‹ Social and family disruption ‹ Patient out of problem context ‹ Nosocomial hazards Interventional Strategy

„ Schedule Meals q 3-4 hours: ‹ Establish and enhance endogenous rhythms of hunger/thirst followed by satiety ‹ Eliminate between meal grazing/sipping ‹ Trust survival physiology „ Provide, do not Coerce: ‹ respect autonomy and survival instinct ‹ avoid defensiveness/aversion „ Harness thirst drive: ‹ Substitute formula/milks for juice, water, etc ‹ Liquids follow solids „ Increase nutrient density of foods offered Caloric Requirements

„ UseUse medianmedian ((““idealideal””)) weightweight forfor heightheight ‹ Fat is metabolically inert ‹ Brain > Visceral Organs > Muscle consume metabolic energy ‹ Consider using weight for cranial(OFC) age if head relatively large compared to length „ MultiplyMultiply xx RDARDA kcal/kgkcal/kg forfor wtwt--ageage oror htht--ageage Estimated Energy Needs (RDA)

AgeAge (years):(years): Kcal/kgKcal/kg bodybody weight:weight: „ 00--11 „ 9090--120120 „ 11--77 „ 7575--9090 „ 77--1212 „ 6060--7575 „ 1212--1818 „ 3030--6060 „ >18>18 „ 2525--3030 Actual weight: 5.2 kg 6 kg is median weight for height age:

[5.2 / 6 = 87% expected wt for length-age] 5.2 kg is 87% of 6 kg weight for length-age Calorie goal:100 kcal/kg x 6 kg = 600 kcal/day For 24 kcal/oz formula (0.8 kcal/ml): 600 kcal/0.8 kcal/ml = 750 ml 750 ml / 30 ml/oz = 25 oz Kcal/kg actual weight: 600kcal/5.2kg = 120 kcal/kg/day 7 month male with early growth arrest attributed to nursing insufficiency. His growth worsened after 5 months age when solids were introduced, despite parental efforts to feed him every 1-2 hours. He improved in wt, Then length after 7 months age when feeding schedule and strategies began. Late cranial growth response Other Interventions

„ SpecializedSpecialized formulasformulas „ Motility/AcidMotility/Acid suppressionsuppression RxRx „ CyproheptadineCyproheptadine „ ZincZinc „ OxygenOxygen „ NasoNaso--gastricgastric feedingfeeding „ NasoNaso--jejunaljejunal feedingfeeding „ PercutaneousPercutaneous endoscopicendoscopic gastrostomygastrostomy Accommodation /Refeeding Risks

„ Chronically malnourished patient is adapted or accommodated to the undernourished steady state. ‹ Reduced metabolic rate, cardiac demand ‹ Depleted intracellular ions: K, P, Ca, Mg ‹ Depleted fat and muscle stores, including myocardium „ Providing nutrients increases metabolic demand: ‹ Increased cardiac demand/stress  Congestive heart failure, edema ‹ Intracellular influx of P, K, Mg, Ca; ‹ P bound in ATP, intermediary metabolism.  Risk of hypophosphatemia, hypoK, hypoMg, hypoCa  Risk of prolonged QTc and ventricular arrhythmia on ECG Indications for Hospitalization

„ ImpairedImpaired homeostasis:homeostasis: ‹ dehydration, hemodynamic or electrolyte disturbance, altered neurologic status, acute weight loss „ Complications/comorbidity:Complications/comorbidity: ‹ infection, respiratory distress, CNS changes „ Negligence/noncompliance/abuseNegligence/noncompliance/abuse „ UnsuccessfulUnsuccessful outpatientoutpatient intervention:intervention: ‹ No weight gain x 2-4 weeks ‹ Sub-optimal gain x 2 months Indications for Discharge

„ RestoredRestored HomeostasisHomeostasis „ ResolvingResolving ComplicationsComplications „ EstablishedEstablished support/monitoringsupport/monitoring systemsystem „ RestoredRestored weightweight gaingain oror anticipatedanticipated weightweight gaingain inin outpatientoutpatient monitoredmonitored contextcontext

Failing to Thrive Thriving to Fail ? Body Mass Index [BMI]: 2 years to 20 years BMI = weight (kg) / height2 (m2)

Extremely Obese: BMI >99th %ile

95 Obese: BMI 95th to <99th %ile 90 85 Overweight: BMI 85th to <95th %ile 75 50 25 10 5

Centers for Disease Control and Prevention Adiposity (Fatness) Rebound To Over-Thrive

„ RapidRapid weightweight gaingain beforebefore ageage 44 monthsmonths isis associatedassociated withwith overweightoverweight atat 77 years.years. Stettler et al Pediatrics 2002;109:194-9 „ CorrelationCorrelation betweenbetween raterate ofof weightweight gaingain inin infantinfant malesmales andand fatnessfatness atat 10.510.5 yearsyears Melbin and Vuille Br J Prev Soc Med 1976;30:239-43 „ AGAAGA infantsinfants withwith rapidrapid weightweight gaingain werewere tallertaller andand fatterfatter atat 99 yearsyears ofof age.age. Cameron et al. Obes Res 2003;11:457-60 To Over-Thrive

„ AdiposityAdiposity ReboundRebound inin BMIBMI << 55 yrsyrs relatedrelated toto increasedincreased adulthoodadulthood BMIBMI ofof 44--55 kg/mkg/m2.. Freedman et al. Int J Obes Relat Metab Disord. 2001;25:543-9 Undernutrition Æ Overnutrition: Metabolic Programming?

„ Smaller(IUGR)Smaller(IUGR) FTFT infantsinfants withwith catchcatch--upup growthgrowth beforebefore ageage 22 yrsyrs werewere tallertaller andand

fatterfatter atat 55 yearsyears ofof age.age. Ong et al. BMJ 2000;320: 967-71 „ LowLow raterate ofof gaingain inin infancyinfancy AND/ORAND/OR rapidrapid weightweight gaingain >> 1212 monthsmonths associatedassociated withwith

increasedincreased coronarycoronary diseasedisease risk.risk. Eriksson et al BMJ 2001; 323:572-3 „9 month FT AGA infant with GER, incarcerated father, nursed and fed hourly. „Why is he so fat? „What strategy do we offer? Beyond FTT: Thriving to Fail

„ EpidemicEpidemic ObesityObesity andand associatedassociated morbiditymorbidity „ InfantileInfantile antecedentsantecedents ofof adultadult ObesityObesity „ InterestInterest inin earlyearly recognitionrecognition „ SymmetrySymmetry withwith diagnosisdiagnosis ofof FTTFTT „ Observation:Observation: ThresholdThreshold forfor referralreferral forfor overweightoverweight greatergreater thanthan thatthat forfor underweightunderweight children.children. „ Miller LA et al: J Pediatr 2002;140:121-4 Can Failure to Thrive Lead to Obesity?

„ PraderPrader--WilliWilli paradigmparadigm „ ControlControl raterate ofof catchcatch--upup weightweight gain.gain. „ LongerLonger termterm monitoringmonitoring ofof recoveredrecovered FTTFTT „ IntakeIntake restrictionrestriction ofof overover--thrivingthriving infantsinfants „ TheThe paradoxparadox ofof grazing:grazing:

‹ ImpairedImpaired appetiteappetite forfor meals:meals: falteringfaltering

‹ ChronicChronic insulinemia:insulinemia: obesigenicobesigenic Recognize Early Signs: Thriving to Fail „ RapidRapid WeightWeight GainGain inin earlyearly childhoodchildhood == HighHigh RiskRisk forfor ObesityObesity inin laterlater lifelife „ DesignateDesignate overweightoverweight asas WeightWeight--forfor--LengthLength greatergreater thanthan 95th%ile95th%ile [WHO[WHO BMIBMI curvescurves existexist forfor << 22 years.]years.] „ WeightWeight gaingain crossingcrossing 22 majormajor percentilespercentiles (1(1 standardstandard deviation)deviation) == upup toto 55 timestimes increasedincreased riskrisk ofof laterlater overweight.overweight. Baird J, et al. BMJ 2005, 12:331(7525):1145

„ EarlyEarly oror infantileinfantile obesityobesity moremore likelylikely associatedassociated withwith geneticgenetic oror endocrineendocrine obesityobesity syndromes.syndromes. Proposed Strategy

„ IdentifyIdentify overover--thrivingthriving infants/toddlersinfants/toddlers „ ScheduleSchedule mealsmeals withwith 33--44 hourhour intervalsintervals „ NoNo grazing,grazing, nibbling,nibbling, sippingsipping betweenbetween „ ControlControl CarbohydratesCarbohydrates asas wellwell asas Fats:Fats: ‹ portionportion control,control, complexcomplex vsvs lowlow glycemicglycemic foodsfoods andand preparation;preparation; ‹ eliminateeliminate fructose/limitfructose/limit sucrosesucrose „ PhysicalPhysical Activity:Activity: limitlimit screenscreen timetime „ FamilyFamily Involvement/EducationInvolvement/Education „ 99 monthmonth FTFT AGAAGA infantinfant withwith GER,GER, incarceratedincarcerated father,father, nursednursed andand fedfed hourly.hourly. „ ResponseResponse toto feedingfeeding strategies;strategies; mommom alsoalso lostlost weight.weight. „ BodyBody massmass indexindex responseresponse toto slowedslowed raterate ofof weightweight gain.gain.