3/16/2018

WI CAN Educational Series Hillary W. Petska, MD, MPH, FAAP Child Advocacy and Protection Services Children’s Hospital of Wisconsin

• Normal patterns of growth • Definition and causes of FTT • Medical evaluation and management • Effects of FTT • Early intervention

• Infants typically lose 5-10% of , but regain by 10-14 days • Double birth weight by 5-6 months • Triple birth weight by 1 year 3/16/2018 3/16/2018

• Infants should be breast or formula fed until 1 yo • Breastfed babies should be given Vit D • Solids can be started around 6 mos • At 1 yo, transition to whole cow’s milk (max: 24 ounces), low fat milk at 2 yo • For kids > 1 yo, limit juice to 4-6 oz/d

• Not all diets are created equal. • Cow milk or low iron formula – iron deficiency • Goat milk – folate deficiency • Raw milk – infection risk • Almond milk – multiple deficiencies • Fruit juice – kwashiorkor

• Mostly diagnosed in children < 2 yo • Seen in 5-10% of children in primary care settings • Accounts for 1-5% of all referrals to children’s hospitals 3/16/2018

• Prolonged cessation of appropriate weight gain compared to age/gender norms • Weight < 3rd percentile • Decline of weight across 2 major percentiles in 6 months 3/16/2018

Actual weight Ideal body weight x 100

% of Ideal Body Weight 3/16/2018 3/16/2018

• Decreased weight in proportion to length = FTT

• Inadequate nutrition: weight, then height, then head circumference affected 3/16/2018

• Decreased length in proportion to weight = endocrine abnormality

• Isolated cessation of head circumference growth = neurologic disorder 3/16/2018

• Proportionate decrease in weight- for-length with normal growth velocity ≠ FTT 3/16/2018

• Intrauterine growth restriction, prematurity, genetic short stature, constitutional growth delay • Conditional growth charts for children with altered growth patterns: • Trisomy 21 (Down syndrome) • Prader-Willi syndrome • Williams syndrome • Cornelia deLange syndrome • Turner syndrome • Rubinstein-Taybi syndrome • Marfan syndrome • Achondroplasia

• • 3/16/2018

FTT is a sign, not a diagnosis

• Inadequate energy intake • Inadequate nutrient absorption • Increased energy requirements

May be due to a medical condition, psychosocial reasons, or both 3/16/2018

• Prematurity • Congenital anomalies • Developmental delay • Intrauterine exposures • Lead poisoning • Dietary beliefs/practices • Any condition that results in inadequate intake, malabsorption, or increased metabolic rate

• Poverty • Social isolation • Domestic violence • Substance abuse • Mental health • Knowledge deficits • Stress

• Comprehensive history and exam can typically r/o medical causes • Observation/history of feeding: • Preparation of formula • Oral-motor dysfunction • Feeding environment • Parent-child interaction 3/16/2018

• Hospitalization may be required: • Diagnostic work- up • Severe malnutrition or dehydration • Refeeding syndrome • Protection

• Multidisciplinary team • Feeding recommendations • Nutrition education • Referral for resources • Close follow-up 3/16/2018

• Neglect • Physical • Environmental • Supervisory • Medical • Emotional • Educational • Abuse • Physical • Sexual

• Poor linear growth • Decreased brain growth • Lower IQ • Developmental delay • Behavioral problems • Increased risk of infection • Poor wound healing • Weak bones • Death

• General appearance • Behavior • Stealing, hoarding food • Disclosures • Reports missing meals 3/16/2018

• Inadequate formula/food • No clean dishes • No electricity • No running water • Safety hazards

• Follow-up with PMD • Medical records request • WIC records • Interview of child and/or siblings at a Child Advocacy Center • Medical/investigator collaboration

• is a common problem.

• Failure to thrive is due to inadequate nutrition, although the underlying cause is typically multifactorial.

• Failure to thrive has significant short- and long-term health consequences.

• Failure to thrive may be a sign of child neglect. 3/16/2018

• Block RW, NF Krebs. Failure to thrive as a manifestation of child neglect. . 116(5):1234-1237; 2005. • DeNavas-Walt C, Proctor BD, Smith JC. U.S. Census Bureau, Current Population Reports, P60-245. Income, Poverty, and Health Insurance Coverage in the United States: 2012. U.S. Government Printing Office: Washington, DC; 2013. • DiMaggio DM, Cox A, Porto AF. Updates in infant nutrition. Pediatr Rev. 38(10):449-462; 2017. • Failure to thrive. In: Pediatric Nutrition: Policy of the American Academy of Pediatrics. 7th ed. Elk Grove Village, Ill.: American Academy of Pediatrics. 663-700; 2014. • Gahagan S. Failure to thrive: A consequence of undernutrition. Pediatr Rev. 27(1):e1-11; 2006. • Harper NS. Neglect: failure to thrive and obesity. Pediatr Clin North Am. 61(5):937-957; 2014. • Homan GJ. Failure to thrive: a practical guide. Am Fam Physician. 94(4):295-299; 2016. • Jaffe AC. Failure to Thrive: Current Clinical Concepts. Pediatr Rev. 32(3):100-107; 2011. • Jenny C (ed). and Neglect: Diagnosis, Treatment, and Evidence. Saunders: St. Louis; 2011. • Kirkland RT, Motil KJ. Etiology and evaluation of failure to thrive (undernutrition) in children younger than 2 years. UpToDate; 2013. • The National Center on Addiction and Substance Abuse (CASA) at Columbia University. No safe haven: Children of substance-abusing parents. New York, NY: The National Center on Addiction and Substance Abuse (CASA) at Columbia University; 1999b. • Osofsky JD. The impact of violence on children. Future Child. 9(3):33-49; 1999. • Schwartz ID. Failure to thrive: an old nemesis in the new millennium. Pediatr Rev. 21(8):257-264; 2000. • Tranchida, Vincent. The Pathology of Fatal Child Neglect. University of Wisconsin School of Medicine and Public Health. Monona Terrace Community and Convention Center, Madison, WI. 15 February 2013. Conference Presentation. • I would also like to acknowledge Dr. Lynn K. Sheets and Dr. Angela L. Rabbitt who provided additional cases/slide content.