DIVISI NUTRISI & PENYAKIT METABOLIK

DEPARTEMEN IKA FK USU / RSHAM

HISTORY, BACKGROUND AND DEFENITIONS
 Pediatricians have described malnourished children with
the words “failure to thrive” (FTT) since at least the
nineteenth century

 Olsen : reviewed the pediatric literature and general

textbooks and found many failed to provide spesific criteria
defining FTT

 Vinton and dietz : term is more euphemism for

undernutrition though growth failure may result from
medical conditions which involve other factors

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 Criteria FTT include:
1. Weight (weight for height) > 2sd below the mean for
sex and / or
2. Weight curve has crossed downward more than 2
major percentile lines (CDC)

 Other alternative:
“Less than the 3rd percentile” or “a weight-for-age (or
weight for height) z-score (or standard deviation
score) lessthan -2.0”

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 Edwards and colleagues:
A child whose weight deviates downwards across two
or more major centiles from the maximum centile
achieved at 4 to 8 weeks for a period of a month or
more

 Alternative or supplemental anthropometric criteria

for FTT including decreased weight velocity, low
triceps skinfold values and midarm circumference

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 EPIDEMIOlOGY
 The prevalence of underweight children can range from 1-
10%

 1996 : (2-5 year old)

- low height for age 5.8%
- low weight for height 2.6%

 Among the children adopted from China

- z-scores were < -2SD in 39% for height, 18% for weight
and 24% for head circumfefence
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MEDICAL RISK FACTORS FOR MALNUTRITION

Risk factors for the development of FTT

 Infant characteristics
- Inadequate intake
- Increased metabolic rate
- Maldigestion or malabsorption
- Premature birth
- Developmental delay
- Congenital anomalies
- Intrauterine toxin exposure
- Plumbism and/or anemia
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 Family characteristics
- Poverty
- Unusual health and nutrition beliefs
- Social isolation
- Disordered feeding techniques
- Substance abuse or other psycopathology
- Violence or abuse

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 Physchosocial risk factors

 Recognition of FTT secondary to neglect or abuse

 The risk factors that should alert the pediatrician to the
possibility of neglect as the cause of FTT include:
- Parental depression, stress, marital strife, divorce
- Mental retardation and pyscological abnormalities in the
parent(s)
- Young and single mothers without social supports
- Domestic violence
- Alcohol or other substance abuse

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- Previous child abuse in the family
- Social isolation and/or poverty
- Parents with inadequate adaptive and social skills
- Parents who are overly focused and career and/or
activities away from home
- Failure to adhere to medical regimens
- Lack of knowledge of normal growth and
development
- Infant with low birth or prolonged
hospitalization
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 Moreover, concerns of abuse or neglect should be raised
during the course of intervention and monitored if the
following become evident:
- Intentional withholding of food
- Strong beliefs in health and/or nutrition regimens that
jeopardize a child’s well-being; and or
- Family that is resistant to recommended interventions
despite multidisciplinary team approach

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APPROACH TO THE PATIENT WITH FTT
 Historical Evaluation of infant and children with
growth failure
- Prenatal
- General obstetric history
- Recurrent miscarriages
- Was the pregnancy planned
- Use of medications, drugs or cigarrettes

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- Labor, delivery and neonatal events
- Neonatal asphyxia or Apgar scores
- Prematurity
- Small for gestational age
- Birthweight and length
- Congenital malformations or infections
- Maternal bonding at birth
- Length of hospitalization
- Breastfeeding support
- Feeding difficulties as neonate

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 Medical history of child
- Regular physician
- Immunization
- Development
- Medical or surgical illness
- Frequent infections
 Growth history
- Plot previous growth points
 Nutrition history
- Feeding behaviour and environment
- Perceived sensitivities or allergies to food
- Quantitative assesment of intake
 Family history
- Maternal and paternal height and weight
- Growth of other siblings
- Gastrointestinal and other systemic diseases

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 Social history
- Age and occupation of parents
- Who feeds the child
- Life stresses
- Social and economic supports
- Perception of growth failure as a problem
- History of violence or abuse by or of caretaker
 Review of systems/clues to organic disease
- Anorexia
- Change in mental status
- Dysphagia
- Stooling pattern and consistency
- Vomiting or gastroesophageal reflux
- Recurrent fevers
- Dysuria, urinary frequency
- Activity level, ability to keep up with peers

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Failure To Thrive (FTT)
 growth deficiency
 faltering or stunted growth
 associated with
 poorer cognitive development,
 learning disabilities,
 long-term behavioral problems.
 Galler JR, Ramsey F, Solimano G, Lowell WE, Mason E. The influence of early malnutrition on subsequent behavioral development:
I. Degree of impairment in intellectual performance. J Am Acad Child Psychiatry.1983;22:8–15

 Corbett SS, Drewett RF, Wright CM. Does a fall down a centile chartmatter? The growth and developmental sequelae of mild failure
to thrive. Acta Paediatr. 1996;85:1278–1283

 Raynor P, Rudolf MCJ. What do we know about children who fail to thrive? Child Care Health Dev. 1996;22:241–250

 Reif S, Beler B, Villa Y, Spirer Z. Long-term follow-up and outcome of infants with non-organic failure to thrive. Isr J Med Sci.
1995;31:483–489
 TREATMENT OF GROWTH FAILURE

 Identified contributing factors, be they biologic,

physhiatric or socioeconomic
 Need:
- long-term treatment and follow-up plan
- involving nutritional advice
- behavioral modification
- social work intervention

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 A general guideline for caloric requirements for infants
with poor growth is

 Kcal per kg required:

RDA for age (kcal/kg) x ideal weight for age
actual weight

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Tabel 1. Recommended dietary allowances (RDA), 1989

Age kcal/kg protein(g)

0-6 month 108 13
6-12 month 98 14
1-3 years 102 16
4-6 years 90 24

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Example
 A 3-month-old boy, weight of 3.6 kg, length of 57 cm
weight-for-age z-score, -2.50; and weight-for-height z-
score, -2.11.
 Waterlow classification: moderate malnutrition (weight
for height 74%)
 RDA for calories: 108 kcal/kg/day, protein: 2.2 g/kg/day
 Ideal weight for length : 4.8 kg
 Caloric requirement for catch up growth (108 x 4.8)/3.6
= 144 cal/kg/day
 Protein requirement for catch up growth (2.2 x 4.8)/3.6
= 2.9 g/kg/day

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 In mild malnutrition, therapy should center on ways to
increase oral caloric intake in an outpatient setting

 Commonly, dietary supplementation with high-calorie

foods, food additives, and age-appropriate high-calori
drinks are recommended to increasing the caloric
density of their formula

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 Infant : respond well to increasing the caloric density of
their formula

 Toddlers and children : use of soils, sour cream, heavy

cream, butter, peanut butter and cheese as dietary
additives is helpful

 Micronutrients: routine supplementation with a zinc

and iron containing multivitamin is probably prudent

 Need for further iron therapy determined by laboratory

evidence of deficiency
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 PROGNOSIS

 Determined by a variety of factors, including:

- genetic potential
- the timing of malnutrition
- the severity of malnutrition
- the presence of underlying medical problems

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PROGNOSIS
 Penderita gagal tumbuh organik: prognosis
berhubungan erat dengan penyakit yang mendasari

 Penderita gagal tumbuh non organik: prognosis

bergantung dari tingkat malnutrisi yang telah timbul
 PREVENTION

 Increased awareness of the medical and psychosocial

factors that may predispose to growth failure
 Classify such patients along the anthropometric
guidelines
 Recognize the benefits of multidisciplinary approach
to difficult management situations

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