Failure to thrive (FTT) atau Gagal Tumbuh

IKG Suandi Department of Pediatrics, School of Medicine Udayana University/Sanglah Hospital

Objectives
Mengetahui definisi dan kriteria pasien dg failure to thrive (FTT) atau gagal tumbuh Mengetahui penyebab atau patofisiologi failure to thrive (FTT) atau gagal tumbuh Mengetahui cara mencegah atau merujuk pasien dg failure to thrive (FTT) atau gagal tumbuh
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Definition
Failure to thrive mula-mula pd awal th.1900 dipakai utk menguraikan:
keadaan malnutrisi1 dan keadaan depresi pd bayi2

Failure to thrive suatu deskripsi dan bukan menyatakan suatu diagnostik:

pada anak yg BB-nya tidak naik-naik3 atau peningkatan BB secara bermakna di bawah BB anak lainnya yg seusia dan berjenis kelamin sama4.
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Table 1. Definitions of Failure To Thrive (FTT)

Attained growth
Weight < 3rd percentile on NCHS growth chart Weight for height < 5th percentile on NCHS growth chart Weight 20% or more below ideal weight for height Triceps skin fold thickness < 5 mm

Rate of growth
Depressed rate of weight gain
< 20 g/d from 0-3 months of age < 15 g/d from 3-6 months of age

Fall-off from previously established growth curve

Downward crossing of > 2 major percentiles on NCHS growth chart

Documented weight loss

Figure 1. The curve of patient with FTT

Delayed 8 weeks or more

Figure 2. The curves of patient with FTT

(Weight)

(Height)

normal

(Head circumference)

Etiology(1)
Faktor-faktor penyebab gagal tumbuh pada bayi dan anak, meliputi:
Penyakit medis yg serius/berat Disfungsi interaksi antara anak dan pengasuhnya Kemiskinan Misinformasi orangtua Child abuse

Figure 3. Nonorganic FTT

Etiology(2)
Mayoritas kasus penyebabnya bukan penyakit organik; tapi gagal tumbuh sering karena problem psikososial
Apakah penyebabnya penyakit primer organik atau psikososial anak akan mengalami malnutrisi dg konsekuensi fisik dan psikologik berisiko long-term physical and psycho-developmental squelae.

Figure 4. Organic etiology (intestinal malrotation)

Abnormal bands

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Figure 5. Pedigree patient with FTT

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Figure 6. Pedigree patient with FTT

Carrier F1 :

F2 :

Unaffected grand father

Unaffected grand mother or grand father Unaffected Mr. A Mrs. A

Carrier grand mother

F3 :

F4 :

Unaffected 8 year old unaffected 18 month old Affected

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Table 2. Causes of inadequate weight gain

1. Inadequate intake: Poverty, misperceptions about diet & feeding practices, error in formula constitution, dysfunctional parent-child interaction, mechanical problems with suck-swallow-feeding, systemic disease resulting in anorexia/food refusal. 2. Calorie wasting: Persistent vomiting, mal-absorption and/or chronic diarrhea, renal losses. 3. Increased caloric requirements: Congenital heart disease, chronic respiratory disease, neoplasm, hyperthyroidism, chronic or recurrent infection. 4. Altered growth potential/regulation: prenatal insult, chromosomal abnormality, endocrinopathies.

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Table 3. Factors influencing nutritional inadequacy in the elderly population

Physiologic
Decreased taste Decreased smell Dysregulation of satiation Delayed gastric emptying Dentition Dysphagia, swallowing problems Diseases (cancer, CHF, COPD, diabetes, ESRD, thyroid) Medication (diuretic, antihypertensive, dopamine agonist, antidepressant, antibiotic, antihistamine) Alcoholism Dementia

Pathologic

Sociologic
Ability to shop for food Ability to prepare food Financial status Low socioeconomic Impaired activities of daily living skills

Psychologic
Depression Anxiety Loneliness

Emotionally stressful life events

Decreased gastric acid Decreased lean body mass

Lack of interactions with others at mealtime

Grief Dysphoria

CHF = congestive heart disease; COPD = chronic obstructive pulmonary disease; ESRD = end stage renal disease

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Keys of aspects of the evaluation

Evaluasi pertumbuhan sekarang dan yg terdahulu:
Riwayat penyakit dan pemeriksaan fisik Perkembangan / kebiasaan observasi makanannya situasi-spesifik dan interaksi global anak-orangtua Pemeriksaan laboratorium selektif tergantung hasil pemeriksaan di atas

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Diagnosis(1)
Bila anak pertumbuhannya buruk fokuskan pada:
Identifikasi gejala dan peny. yg mendasari. Tingkat beratnya malnutrisi. Penting mencari tanda-tanda spt. kekerasan fisik (physical abuse) / terlantar/tidak diinginkan atau tingkah-laku yg menyimpang

Interaksi orangtua-anak
Perhatikan waktu anak makan cara ini utk mengidentifikasi tingkah-laku spesifik atau masalah interaksi selama makan.
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Figure 7. Enteropathology of patient with diarrhea and FTT

Abnormal villous & mucosa

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Figure 8. Organic abnormality of a patient with FTT

Abnormal brain

Distended abdomen

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Diagnosis Diagnosis(2)
Perkembangan Psychomotor:
Bila anak gagal tumbuh psikososial berat manifestasi bermacam-macam dari hyperalert, perhatiannya berlebihan sampai menolak kontak mata dan apathetic withdrawal.
Beberapa anak manifes perkembangan terhambat, terutama pada area bahasa dan tingkah-laku adaptif sosial tergantung pada stimulasi lingkungan.

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Figure 9. Patients with FTT

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Diagnosis(3)
Pemeriksaan laboratorium:
Tergantung riwayat penyakit, pem. fisik, data pertumbuhan, dan peny. organik.
Studi laboratorium utk menentukan status nutrisi dan masalah anemia defisiensi besi. Pemeriksaan Lab.: darah lengkap, serum elektrolit, serum kreatinin, total protein/albumin, urinalysis, kultur urine, and bone age (bila tinggi badan juga buruk).
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Management(1)
Evaluasi dan tatalaksana secara obat-jalan.
Gagal tumbuh psikososial perlu MRS bila berisiko tinggi, mengalami kekerasan fisik / terlantar, malnutrisi berat atau scr medis tidak stabil, atau tatalaksana obatjalan mengalami kegagagalan. Tatalaksana gagal tumbuh psikososial bersifat individu tergantung kebutuhan spesifik anak dan keluarga.

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Management(2)
Rehabilitasi nutrisional difokuskan pd upaya mengoreksi:
Interaksi anak-orangtua Misinformasi orangtua Tuntunan makanan spesifik Kebutuhan psikososial keluarga.

Pendekatan tim multidisiplin:

Meliputi pekerja sukarela / pekerja sosial, nutrisionis, spesialis perilaku anak, dan community-based outreach services.
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Summary

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