Failure to thrive: Difference between revisions

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{{Adult top}} [[failure to thrive (peds)]]
==Background==
==Background==
* Non-specific term indicating inappropriate weight loss or insufficient weight gain, due to insufficient caloric intake, caloric absorption, or excessive caloric demand.
* Usually multi-factorial and seen in patients with chronic illnesses.  
* Separated into pediatric and adult (often seen in geriatric populations or in those with chronic illnesses).
* Defined as unintended weight loss >5% from baseline, decreased appetite, poor nutrition, inactivity, and often accompanied by [[dehydration]], [[depression|depressive symptoms]], and impaired immune function.
==Pediatric==
 
* Defined as weighing <5th percentile for age and sex, or weight deceleration crossing two major growth lines on a growth chart.
==Clinical Features==
* Does not imply a defect in social, intellectual, or emotional development, but if untreated may lead to any combination of those.
* Non-specific term indicating inappropriate weight loss or insufficient weight gain, due to insufficient caloric intake, insufficient caloric absorption, or excessive caloric demand.  
* Classically divided into endogenous (medical) and exogenous (psychosocial or environmental) causes
===Evaluation===
* A detailed history and physical examination (including accurate height and weight) are usually sufficient to establish a cause. Over 80% of cases are due to insufficient caloric intake from exogenous causes.
** History should focus on breastfeeding technique, frequency, and duration, or amount of formula and method of preparation.
** Observed feeds can often be useful to identify problems.
* If an endogenous cause is suspected, specific lab tests or imaging studies may be helpful to evaluate for metabolic abnormalities, the presence of infections, malignancy, or anatomic malformations. Additional testing should be ordered on a case by case basis and is only recommended if a specific etiology is suspected.  
===Differential Diagnosis===
====Endogenous Causes====
* GERD
* IBS
* Food allergy
* Malabsorption
* Pyloric stenosis
* Gastrointestinal atresia or malformation
* Inborn error of metabolism
* Thyroid disorder
* Chronic infection or immunodeficiency
* Chronic pulmonary disease
* Congenital heart disease or heart failure
* Malignancy
* Celiac disease
* Inflammatory bowel disease
===Exogenous Causes===
* Breastfeeding problem (latching, suckling, or swallowing)
* Improper formula preparation
* Caregiver depression
* Lack of food availability
* Cleft lip/palate
* Mood disorder
* Eating disorder
* Child neglect or abuse
===Management===
* Most cases can be discharged with PCP follow up. PCPs can make appropriate referrals for nutritional counseling, lactation coaching, or formula supplementation.
* Indications for hospitalization include failure of outpatient management, suspicion of endogenous cause requiring urgent management, suspicion of abuse or neglect, signs of traumatic injury, severe psychosocial impairment of the caregiver, or evidence of serious malnutrition (<70th percent of predicted weight for length).
==Adult==
* Usually multifactorial and seen in patients with chronic illnesses.  
* Patients often have a combination of physical impairment, malnutrition, depression, and cognitive impairments.  
* Patients often have a combination of physical impairment, malnutrition, depression, and cognitive impairments.  
* Defined as unintended weight loss >5% from baseline, decreased appetite, poor nutrition, inactivity, and often accompanied by dehydration, depressive symptoms, and impaired immune function.
===Evaluation===
==Differential Diagnosis==
* Chronic or recurrent [[infection]]s
* Immunodeficiency
* Endocrine disorder
* Cancer
* Chronic lung disease
* Chronic [[renal failure|renal insufficiency]]
* [[Heart failure]]
* [[Hepatic failure]]
* Chronic wounds
* Hip or other large bone [[fracture]]
* [[Inflammatory bowel disease]]
* Malabsorption or malnutrition
* Rheumatologic diseases (e.g. [[RA]], [[SLE]]
* [[Stroke]]
* [[Depression]]
* [[Dementia]]
* [[Psychosis]]
* Medication side effects or interactions
** [[Anticholinergics]], [[antiepileptics]], [[benzodiazepines]], [[beta blockers]], central [[alpha antagonists]], [[diuretics]], [[steroids]], neuroleptics, [[opioids]], [[SSRIs]], and [[TCAs]] are common culprits
 
==Evaluation==
* History and physical examination are often sufficient to make the diagnosis. Many elderly patients with failure to thrive will be unable to provide an accurate history, so family members or caregivers must be involved.
* History and physical examination are often sufficient to make the diagnosis. Many elderly patients with failure to thrive will be unable to provide an accurate history, so family members or caregivers must be involved.
** A thorough review of medications is necessary, as polypharmacy may contribute to failure to thrive.  
** A thorough review of medications is necessary, as polypharmacy may contribute to failure to thrive.
** A Mini Mental Status Exam (MMSE) should be performed to screen for cognitive decline.
*CBC, CMP, [[UA]], [[ECG]], and [[CXR]] are usually indicated
* Limited laboratory and imaging studies are recommended to screen for treatable medical conditions that may contribute to failure to thrive.  
*Consider:
** CBC with cultures, CMP, ESR, CRP, TSH, UA, HIV, RPR, PPD, and CXR are usually indicated.
**[[troponin]], cultures, [[head CT]], ESR, CRP, TSH, HIV, RPR
===Management===
**[[Mini Mental Status Exam]] to screen for cognitive decline
 
==Management==
*If a specific medical cause can be identified, treatment should be tailored to the etiology, taking into account the potential risks for already frail patients.  
*Oftentimes, treatment will involve nutritional supplementation, physical/occupational/speech therapy, modifications of living environment, and treatment of depression and/or dementia.
 
==Disposition==
*Some patients can be discharged from the ER with PCP follow up.
*Evaluate for ability to care for at home and possible need for placement
*If failure to thrive is severe or refractory to treatment, consider goals of care discussions and a hospice referral
 
==See Also==
*[[Failure to thrive (peds)]]
 
==External Links==
 
 
==References==
<references/>
 
[[Category:FEN]]

Latest revision as of 23:05, 28 November 2019

This page is for adult patients. For pediatric patients, see: failure to thrive (peds)

Background

  • Usually multi-factorial and seen in patients with chronic illnesses.
  • Defined as unintended weight loss >5% from baseline, decreased appetite, poor nutrition, inactivity, and often accompanied by dehydration, depressive symptoms, and impaired immune function.

Clinical Features

  • Non-specific term indicating inappropriate weight loss or insufficient weight gain, due to insufficient caloric intake, insufficient caloric absorption, or excessive caloric demand.
  • Patients often have a combination of physical impairment, malnutrition, depression, and cognitive impairments.

Differential Diagnosis

Evaluation

  • History and physical examination are often sufficient to make the diagnosis. Many elderly patients with failure to thrive will be unable to provide an accurate history, so family members or caregivers must be involved.
    • A thorough review of medications is necessary, as polypharmacy may contribute to failure to thrive.
  • CBC, CMP, UA, ECG, and CXR are usually indicated
  • Consider:

Management

  • If a specific medical cause can be identified, treatment should be tailored to the etiology, taking into account the potential risks for already frail patients.
  • Oftentimes, treatment will involve nutritional supplementation, physical/occupational/speech therapy, modifications of living environment, and treatment of depression and/or dementia.

Disposition

  • Some patients can be discharged from the ER with PCP follow up.
  • Evaluate for ability to care for at home and possible need for placement
  • If failure to thrive is severe or refractory to treatment, consider goals of care discussions and a hospice referral

See Also

External Links

References

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