Failure to thrive: Difference between revisions

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==Background==
==Background==
* Non-specific term indicating inappropriate weight loss or insufficient weight gain, due to insufficient caloric intake, insufficient caloric absorption, or excessive caloric demand.  
* Non-specific term indicating inappropriate weight loss or insufficient weight gain, due to insufficient caloric intake, insufficient caloric absorption, or excessive caloric demand.  
* Separated into pediatric and adult (often seen in geriatric populations or in those with chronic illnesses).
==Pediatric==
* Defined as weighing <5th percentile for age and sex, or weight deceleration crossing two major growth lines on a growth chart.
* Does not imply a defect in social, intellectual, or emotional development, but if untreated may lead to any combination of those.
* 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.  
* 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.
* 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===
 
* 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.
==Clinical Features==
** 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.
* Limited laboratory and imaging studies are recommended to screen for treatable medical conditions that may contribute to failure to thrive.
** CBC with cultures, CMP, ESR, CRP, TSH, UA, HIV, RPR, PPD, and CXR are usually indicated.
===Differential Diagnosis===
===Differential Diagnosis===
* Chronic or recurrent infections
* Chronic or recurrent infections
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* Medication side effects or interactions
* Medication side effects or interactions
** Anticholinergics, antiepileptics, benzodiazepines, beta blockers, central alpha antagonists, diuretics, steroids, neuroleptics, opioids, SSRIs, and TCAs are common culprits
** 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.
** 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.
* Limited laboratory and imaging studies are recommended to screen for treatable medical conditions that may contribute to failure to thrive.
** CBC with cultures, CMP, ESR, CRP, TSH, UA, HIV, RPR, PPD, and CXR are usually indicated.
===Management===
===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.  
*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.  
*Oftentimes, treatment will involve nutritional supplementation, physical/occupational/speech therapy, modifications of living environment, and treatment of depression and/or dementia.
 
==Disposition==
*Most patients can be discharged from the ER with PCP follow up.
*Most patients can be discharged from the ER with PCP follow up.
*If failure to thrive is severe or refractory to treatment, goals of care discussions with the patient and their family should be initiated, and a hospice referral may be indicated.
*If failure to thrive is severe or refractory to treatment, goals of care discussions with the patient and their family should be initiated, and a hospice referral may be indicated.
==See Also==
*[[Failure to thrive (peds)]]
==External Links==
==References==
<references/>
[[Category:FEN]]

Revision as of 22:01, 21 October 2017

Background

  • Non-specific term indicating inappropriate weight loss or insufficient weight gain, due to insufficient caloric intake, insufficient caloric absorption, or excessive caloric demand.
  • Usually multifactorial and seen in patients with chronic illnesses.
  • 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.

Clinical Features

Differential Diagnosis

  • Chronic or recurrent infections
  • Immunodeficiency
  • Endocrine disorder
  • Cancer
  • Chronic lung disease
  • Chronic renal insufficiency
  • Heart failure
  • Hepatic failure
  • Chronic wounds
  • Hip or other large bone fracture
  • Inflammatory bowel disease
  • Malabsorption or malnutrition
  • Rheumatologic diseases
  • 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.
    • 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.
  • Limited laboratory and imaging studies are recommended to screen for treatable medical conditions that may contribute to failure to thrive.
    • CBC with cultures, CMP, ESR, CRP, TSH, UA, HIV, RPR, PPD, and CXR are usually indicated.

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

  • Most patients can be discharged from the ER with PCP follow up.
  • If failure to thrive is severe or refractory to treatment, goals of care discussions with the patient and their family should be initiated, and a hospice referral may be indicated.

See Also

External Links

References

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