Dilek A. Bishku c://lectures/FTT Helpful Hints Handout July 29, 2005 HELPFUL HINTS: 1.

Before any intervention make sure that the child is actually has failure to thrive, not just small Remember that 3-5 % of the healthy population, by definition, will be below the -2SD of the norm. (Your clues will be parental heights, proportionality, birth weight, gestational age, birth length and most importantly past trajectory.) IUGR kids: if their birth length was normal expect excellent catch-up growth. They are actually at risk for future obesity. If birth length is also below the 5 th percentile, they are likely to remain small. One data point raises red flags. Diagnosis of FTT requires follow up (prospective or retrospective) over time. A good start as a f/u interval is Qweek or Q2w weight-checks. You can gradually increase it as the child starts to catch up. The requirements should be individualized as soon as possible. The guidelines are for populations. Remember the bell curve. There is a huge distance between two tails of it and what is appropriate for one half of the population is too much or too llittle for the other half. Your job in the clinic is not to teach nutrition 101. The caregiver is not interested in learning what works for the average x-year-old. They are there, mostly because what works for the average child has not worked for this little one. Remember: siblings are NOT controls. Do not rule out abuse or neglect just because other sibs are fine. It is typical for only one of the children to have FTT due to neglect. Use the appropriate charts. Especially for special medical conditions and 1 st generation immigrants. But, it is always better to use them together w/ the CDC charts. As you all know, HISTORY is the most important part of the evaluation.

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10. Was the pregnancy planned? It may be useful in uncovering attachment problems, but difficult to ask directly. I find it easier to ask How long into the pregnancy did you find out that you were pregnant? Mothers usually volunteer information if they did not want the child. 11. Genetics referrals can be helpful, to adjust expectations and setting realistic goals, if nothing else. 12. There is no FTT Battery of labs. Send your CBC and CMP, but everything else should depend on indications. 13. Observe at least one feeding. There is a validated scale (NCAST) to score feeding interaction. 14. Collaborate w/ speech closely. Most of preferences or dislikes are based on oromotor problems (or sometimes intolerances) 15. The absolute threshold for referral is developmental delay. (By the way, developmental delay is a very unfortunate euphorism. The correct term should be developmental loss)

Dilek A. Bishku c://lectures/FTT Helpful Hints Handout July 29, 2005 16. The minimal catch up growth is around 10 gms/day. 15 gm/day is a realistic expectation. Be happy w/ 20 gm/day. Celebrate at 30 gm/day. 17. the nutrition support sequence is : 3 meals+2 snacks supplements tube feeding TPN Tube feeding is either NG, NJ or G-tube. There is no reason under the sun to feed a child with a NG tube for more than 4-6 weeks.

18. FTT etiologies can be divided into three groups: Organic, inorganic and mixed. Mixed constitutes 99.9% of the total, making the grouping absolutely meaningless. 19. psychosocial etiology and environmental reasons do NOT imply neglect no matter how much DCFS workers wish that they do.

20. Make sure that the family has the resources and the skills to follow recommendations and confirm who the caregiver is before going ahead with interventions. 21. Make sure all eligible patients sign up w/ WIC, Food Stamps. 22. Think twice before giving waiver letters to mothers for FTT. Rare, but very unfortunately, there are some cases where these letters cause a conflict of interest. 23. If in doubt and wish to discuss FTT cases, call me anytime. Phone: 773-363-6700 (La Ra) x 409 Pager : 2176 Also can call FTT Case Manager: Ida Mabry Ext: 397

CLASSIFICATION OF MALNUTRITION IN CHILDREN:

Mild Malnutrition

Moderate Malnutrition

Severe Malnutrition

Percent Ideal Body Weight

80-90%

70-79%

< 70%

Percent of Usual Body Weight

90-95%

80-89%

< 80%

Albumin (g/dL)

2.8-3.4

2.1-2.7

< 2.1

Transferrin (mg/dL)

150 - 200

100 - 149

< 100

Total Lymphocyte Count (per L)

1200 - 2000

800 - 1199

< 800

Dilek A. Bishku c://lectures/FTT Helpful Hints Handout July 29, 2005

Gomez Classification: The child's weight is compared to that of a normal child (50th percentile) of the same age. It is useful for population screening and public health evaluations. percent of reference weight for age = ((patient weight) / (weight of normal child of same age)) * 100

percent of reference weight for age

Interpretation

90 - 110%

normal

75 - 89%

Grade I: mild malnutrition

60 - 74%

Grade II: moderate malnutrition

< 60%

Grade III: severe malnutrition

Wellcome Classification: evaluates the child for edema and with the Gomez classification system.

Weight for Age (Gomez)

With Edema

Without Edema

60-80%

kwashiorkor

undernutrition

< 60%

marasmic-kwashiorkor

marasmus

Waterlow Classification: Chronic malnutrition results in stunting. Malnutrition also affects the child's body proportions eventually resulting in body wastage. percent weight for height = ((weight of patient) / (weight of a normal child of the same height)) * 100percent height for age = ((height of patient) / (height of a normal child of the same age)) * 100

Dilek A. Bishku c://lectures/FTT Helpful Hints Handout July 29, 2005

Weight for Height (wasting)

Height for Age (stunting)

Normal

> 90

> 95

Mild

80 - 90

90 - 95

Moderate

70 - 80

85 - 90

Severe

< 70

< 85

Serum Albumin: considered to be the single best nutritional test to predict patient outcome. breakpoint for clinically relevant malnutrition: ranges from 3.0 to 3.5 g/dL

Level of Malnutrition

Albumin g/dL

normal

3.5 - 4.8

mild

2.8 - 3.4

moderate

2.1 - 2.7

severe

< 2.1

Instant Nutritional Assessment: uses measurements of serum albumin and total lymphocyte counts at admission to evaluate the patient's nutritional status.

Serum Albumin

Total Lymphocyte Count

Complications

Death

>= 3.5 g/dL

>= 1500 per L

3.0%

0.9%

>= 3.5 g/dL

< 1500 per L

7.5%

2.2%

< 3.5 g/dL

>= 1500 per L

23.8%

0%

Dilek A. Bishku c://lectures/FTT Helpful Hints Handout July 29, 2005

< 3.5 g/dL

< 1500 per L

11.8%

17.6%

Nutritional Needs: A simple rules of thumb: typical formula and breast milk are 20 kcal/oz

Group

Particular s

Body WtKg

Net energy kcal/d

Protei n g/d

Fat g/d

Calciu m mg/d

Iron mg/d

Vit.A. pg/d retino l

Vit.A. pg/d carotene

Infants

0-6 months 6-12 months

5.4

108/kg

2.05/kg 500

8.6

98/kg 1.65/kg 350 25 25 400 400 12 400 1200 1600

1-3 years

12.2

1240

22

Children

4-6years

19.0

1690

30

18

400 2400

25 7-9 years Boys 10-12 years 10-12 years 26.9 35.4 1950 2190 41 54 22 31.5 1970 57

400 26 34 600 19 600 600

2400

Girls

Up to 5 years of age begin with a base of 1,000 calories and add 100 calories for each year. (e.g. a 1 year-old would need approximately 1000 + 100 calories= 1100 calories/day, a 2 year-old would need 1000 + 200 calories= 1200 calories/day.) EATING SKILLS ALONG DEVELOPMENTAL STAGES: 4-6 Months: sits independently, reaches for objects, begins lip sound play - smacks, purses lips, voluntarily moves lips and tongue, begins muchning pattern offer soft, semi-solid, pureed foods from spoon; e.g., infant cereal, pureed vegetables and fruits 7-8 Months: reaches for objects, brings hand to mouth, begins tongue lateralization finger-feeding large pieces of food, offer ground junior or mashed table foods 8-10 Months: holds bottle to drink, puts lips on rim of cup, diagonal chewing emerges introduce cup, offer coarsely chopped table foods, easily chewed soft meats 11-12 Months: rotary chewing begins, swallows with lips closed, picks up cup independently, takes 4-5 continuous swallows increase textures, include more table foods, begin spoon feeding, continue to encourage drinking from cup 18 Months: tongue clears upper and lower lips, can spoon-feed, drinks from cup independently increase the number of foods

Dilek A. Bishku c://lectures/FTT Helpful Hints Handout July 29, 2005 from the family's menu; e.g., tender meats, soft fruits and vegetables fork continue to increase variety of textures in food pattern 24 Months: begins to use

NUTRITIONAL SUPPORT: Consider the degree of malnutrition, adequacy of GI function and the foreseen duration of need. According to the need you can use: regular meals: GI tract absorption is adequate and nutritional needs are normal or slightly increased (e.g. neglected child who did not have enough to eat.) oral supplements: GI tract absorption is adequate but routine meals are not enough to meet caloric needs (e.g. Pediasure, Ensure after meals, for babies MCT oil in formula to boost growth) tube feedings: GI tract absorption is adequate but meals and oral supplements are insufficient (e.g. NG if post trauma, trial to see if wt gain is possible. More than 4-6 wks move towards G-tube. Outpt: bolus is better, for wt gain or in house may prefer continuous.) TPN: if the GI tract absorption is inadequate (e.g. child w/shor t gut)