Failure to thrive means poor weight gain in infancy and early childhood. In the other hand, if we plot the growth chart, the weight crosses centile lines in a downward position. The birth weight might be normal however normal weight gain does not occur. If the problem is prolonged, the height ad head circumference will be affected.
Some clinical features that can be found are thin or wasted buttocks. There is also loss of subcutaneous fat with poor muscle bulk. In malabsorption cases, abdominal distension will be common. Occasionally, the child also presents with rickets due to vitamin D deficiency. All cases of failure to thrive will have abnormal growth chart.
How to observe growth and failure to thrive??
- Behavior and activity level. Either the child is active or not.
- We have to see the general health of the baby. The baby might easily get sick, frequent fever, etc. Happiness of the child might influence this growth.
- We have to look for any signs of abuse. The child might not get proper attention by care taker and might even be neglected, do not get enough food, etc.
- Family finances also give a big influence. Poverty is the chief problem where this child might have difficulty at home, food and emotion deprivation and even unskilled feeding techniques by care taker (this problem often is seen in developing countries.
- Family height charting also should be needed. If both parents are small size, we cannot expect the child to be big and tall.
- A growing child needs a lot of nutrition and energy for body and brain growth. Hence the feeding patterns also play an important role. For example, frequent feeding up to 3 hours is essential for baby less than 6 months.
- Any parental illness
- Dysmorphic baby (baby with chromosomal abnormality) also might influence a child growth.
Causes of failure to thrive:
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More common causes of failure to thrive include:
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- Inadequate intake – this is the most common cause especially and developing country.
- Psychosocial deprivation
- Familial short stature
- ‘small for dates’ neonate
- Malabsorption causes like intestinal infection and celiac disease.
- Mental retardation
- Iatrogenic cause, for example in child taking corticosteroid
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Less common causes include:
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- Systemic disease like cystic fibrosis, cyanotic congenital heart disease, very severe asthma (with frequent attack) and chronic renal failure.
- Chronic infection like malaria.
- Malabsorption that cause by tropical infestation and Hirschsprung’s disease
- Skeletal disorders like rickets and achondroplasia
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Uncommon causes of failure to thrive:
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- Endocrine disorder like hypopituarism and hypothyroidism
- Chromosomal abnormality like the one we see in Down’s syndrome
- Metabolic causes like glycogen storage disease and renal tubular acidosis
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In terms of investigation, dietary assessment is the most important part. Blood investigations may be needed in few cases to look for anemia and electrolytes. Anemia and steatorrhoea are suggestive of malabsorption. In rare case like cystic fibrosis, sweat test may be done. Cystic fibrosis is more common in Western countries. For the diagnosis of celiac disease, jejuna biopsy will be indicated.
Management of each case will be different depending on the causes of failure to thrive; adequate nutrition is enough for vast majority of patients that have poor oral intake. Failure to thrive needs early intervention. The first few years of life is very important for the child’s growth and developmental, if the child do not get enough nutrition, it will only affects the growth of important organs like brain, but may also lead to developmental delay.
Reference:
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- Quick Reference Cards by Medical Protection Society. 2001.
- Oxford Handbook of Clinical Specialties. 5th edition. 2001.
- Paediatrics color guide. Churchill Livingstone. 2d edition. 1997.
Chronic lung disease (CLD) is also known as bronchopulmonary dysplasia (BPD). It is defined as oxygen dependency at 28 days with the present of clinical evidence of respiratory distress together with abnormal chest radiograph. The infants may require oxygen supplement after 28th day of life in order to keep partial O2 50mmHg. Chest X ray showing diffuse abnormalities characteristic of BPD. CLD arise as a consequence of the treatment of preterm and term infants that has suffered with primary respiratory disease. Commonly, it affects preterm infants born with hyaline membrane disease or infants with respiratory distress syndrome (RDS).
It is important to ensure that oxygen saturation is normal by obtained adequate oxygen therapy. SPO2 of 93-95% in older infants is optimal. Nutrition is vital aspect to ensure normal growth of these babies. Steroids have shown to have limited values in weaning the child from ventilation support or reducing the oxygen need. Therefore, postnatal steroids should be wisely reserved for those cases that are at risk of dying de to chronic lung disease. This child also should fully immunized to make sure that hey have enough protection from infection. A course of 5 injections of palivizumab should be given to all infants with CLD to reduce the risk of RSV infections. Palivizumab is a humanized monoclonal antibody which prevents entry of RSV (respiratory syncytial virus) into host cells. Vaccination for influenza is highly recommended.
In term of prognosis, most babies with chronic lung disease will eventually outgrow their disease. Some will outgrow the illness while they are still admitted in NICU. However, there are few long term complications of CLD that should be considered. During adolescence, the main airway changes are includes airway obstruction, lung hyper reactivity and inflation. There is evidence that this will increase risk for chronic obstructive pulmonary disease (COPD) for this group of patient later in their life.
References:
1. Beattie, J. and Carachi, R. Practical paediatrics problems. London.Hodder Arnold; 2005.
2. Ferri, F.F. Ferri’s clinical advisor instant diagnosis and treatment. Philadelphia: Mosby Elsevier; 2008.
3. Guidelines Global Initiative for Chronic Obstructive Lung Disease. 2009. Available online at: http://www.goldcopd.com/
