Rosen & Barkin's 5-Minute Emergency Medicine Consult (263 page)

• Not a single disease, but a description of a group of symptoms
  
• Inadequate physical growth:
  
  • Usually diagnosed earlier than age 2 yr
    
• Broadly divided into:
  
  • Organic (underlying medical condition)
    
  • Nonorganic (no underlying medical condition)
    
• Found in all socioeconomic groups
  
• Poverty increases risk of failure to thrive (FTT)
  
• May result in long-term growth, behavioral, and developmental difficulties, particularly in children who fail to thrive in the first few months of life
  

Many diseases with unique causes resulting in 1 or more of:

• Inadequate caloric intake
  
• Inadequate caloric absorption, malabsorption
  
• Excessive caloric expenditure
  
• These may be secondary to underlying chronic disease
  

DIAGNOSIS

• No universally accepted definition
  
• Failure to achieve or maintain a growth rate appropriate for age
  
• Weight less than 2 standard deviations below normal for age (corrected for prematurity) and sex
  
• Weight that crosses downward through 2 major percentiles (major percentiles are 5th, 10th, 25th, 50th, 75th, and 90th percentiles) on standard growth chart (see Additional Reading below)
  
• There is an associated change in the velocity of growth of 1 or more growth parameters. Any of the 3 routinely monitored growth parameters may be impaired initially:
  
  • Weight loss initially followed by impaired growth in length/height and finally head circumference usually caused with caloric inadequacy.
    
  • Primary length/height fall-off often associated with endocrinology problem
    
  • Impairment in growth of head circumference commonly caused by CNS primary condition.
    
• Although the pattern is usually one of slow decrease in growth velocity, an abrupt change may occur, usually indicative of an organic origin.
  
• Can manifest as:
  
  • Reduced muscle mass
    
  • Loss of subcutaneous fat
    
  • Alopecia
    
  • Dermatitis
    
  • Chronic disease
    
  • Marasmus
    
  • Kwashiorkor
    
  • Associated endocrinologic findings
    
  • Abnormal neurologic exam and development
    
  • Decreased immunologic function and increased risk of infection
    

• Detailed feeding history:
  
  • Breast-feeding:
    
    • Prior breast-feeding experience
      
    • Frequency of feedings
      
    • Length of feedings
      
    • Family support for breast-feeding
      
  • Formula:
    
    • Type of formula (milk, soy, elemental, preemie)
      
    • How formula is prepared (ready to feed, powder, liquid concentrate)
      
    • Frequency of feedings
      
    • Volume per feeding
      
  • Solid foods
    
  • Vomiting associated with feeds
    
  • Urine and stool output:
    
    • Blood in stool
      
• Gestational history:
  
  • Maternal medical complications
    
  • Drug or alcohol use
    
• Birth history:
  
  • Complications, intrauterine growth retardation, prematurity
    
  • Birth weight
    
  • Congenital anomalies
    
  • Intrauterine exposures/infections
    
• Developmental history:
  
  • Achievement of appropriate milestones
    
  • Child’s perceived temperament
    
• Psychosocial history:
  
  • Family composition
    
  • Family/social support
    
  • Stresses
    
  • Maternal depression
    
  • Abuse or neglect
    

• Weight, length/height, head circumference:
  
  • Plotted on appropriate growth chart:
    
    • Include as many prior growth points as possible
      
• Dysmorphic features:
  
  • Cardiac disorders
    
  • Pulmonary disorders
    
  • GI disorders
    
• Skin exam to include signs of child abuse
  

• Detailed history and physical exam
  
• Growth parameters plotted on appropriate growth charts
  
• Observation of family–child interaction
  
• Direct observation of feeding
  
• CBC, CRP, electrolytes, urinalysis and urine culture, and if indicated, lead level
  

• CBC:
  
  • Anemia
    
  • Infection
    
  • Leukemia/malignancy
    
  • Lead level
    
  • Lead poisoning
    
• Chemistry panel (electrolytes, BUN, creatinine, glucose, liver function, protein, albumin, calcium, phosphate, magnesium):
  
  • Hydration and acidosis
    
  • Metabolic and endocrinologic disorders including thyroid disease. Often checking the routine newborn screening (NBS) is useful
    
  • Diabetes mellitus
    
  • Renal disease
    
  • Blood gas analysis
    
  • Renal tubular acidosis
    
  • Inborn errors of metabolism
    
• Urinalysis with culture:
  
  • Renal disease
    
  • Infection
    
• HIV
  
• Stool studies including occult blood, culture, and ova and parasites
  

• CXR:
  
  • TB
    
  • Pneumonia
    
  • Cardiomegaly
    
• Bone age
  

• pH probe:
  
  • Gastroesophageal reflux
    
• Sweat chloride test:
  
  • Cystic fibrosis (may be part of NBS)
    
• Tuberculin skin testing
  

• Organic causes:
  
  • GI:
    
    • Malabsorption syndromes
      
    • Celiac disease
      
    • Cystic fibrosis
      
    • Food allergy
      
    • Inflammatory bowel disease
      
    • Hepatobiliary disease
      
    • Hepatitis
      
    • Cirrhosis
      
    • Biliary atresia
      
    • Obstructive disease
      
    • Pyloric stenosis
      
    • Malrotation
      
    • Hirschsprung disease
      
    • Pancreatitis
      
    • Short gut syndrome
      
    • Gastroesophageal reflux
      
    • Vitamin deficiencies
      
  • Cardiac:
    
    • Congenital heart disease
      
    • Cyanotic
      
    • Congestive
      
    • Acquired heart disease
      
  • Pulmonary:
    
    • Bronchopulmonary dysplasia
      
    • Obstructive sleep apnea
      
    • Chronic lung disease
      
    • Cystic fibrosis
      
  • Hematologic/oncologic:
    
    • Iron-deficiency anemia
      
    • Thalassemia
      
    • Lead poisoning
      
    • Leukemia
      
  • Renal:
    
    • Chronic renal insufficiency
      
    • Renal tubular acidosis
      
    • Recurrent UTIs
      
  • Neurologic/CNS:
    
    • Hydrocephalus
      
    • Hypertonia/hypotonia
      
    • Generalized weakness (i.e., spinal muscular atrophy)
      
    • Oromotor dysfunction
      
  • Immunologic:
    
    • AIDS
      
  • Endocrine:
    
    • Diabetes mellitus
      
    • Thyroid/parathyroid disease
      
    • Adrenal disease
      
    • Growth hormone deficiency
      
    • Hypopituitarism
      
    • Hypophosphatemic rickets
      
  • Infectious:
    
    • TB
      
    • Parasite
      
    • UTI
      
  • Genetic/congenital:
    
    • Fetal alcohol syndrome
      
    • Smith–Lemli–Opitz syndrome
      
    • Cleft lip/palate
      
    • Inborn errors of metabolism
      
    • Many genetic syndromes can contribute.
      
  • Toxic
    
• Nonorganic causes:
  
  • Parent–child dysfunction:
    
    • Mother–infant bonding problems
      
    • Maternal mental illness/substance abuse
      
    • Inexperienced mother
      
    • Breast-feeding difficulties
      
    • Improper formula preparation
      
    • Inadequate availability of formula
      
    • Chaotic family environment
      
    • Child abuse or neglect
      
    • Munchhausen syndrome by proxy
      

TREATMENT

• Check for hypoglycemia
  
• Fluid resuscitation when dehydrated
  
• Supportive/nonjudgmental environment
  

• Recognize/identify child with FTT
  
• Rule out organic abnormalities:
  
  • Organic causes may have specific treatments.
    
• Social services consult
  
• Breast-feeding consult:
  
  • Advise on appropriate feeding.
    

Dependent on underlying cause

FOLLOW-UP

• Organic cause requiring medical admission
  
• Nonorganic causes to observe caregiver–child interaction
  
• Nonorganic causes to observe weight while monitoring oral intake. This is particularly appropriate in children <3–6 mo of age because of the potential impact upon cognitive development
  
• Suspected child abuse/neglect
  
• Severe dehydration, malnutrition, or electrolyte imbalance