User:Bts200/sandbox

Work plan:
In the next 4 weeks I will be working on this article as part of my curriculum at my medical school. Failure to thrive is a common problem with the pediatric population, and one that has many potential causes. Understanding the intricacies of the disorder and the multifaceted nature of its origins can better help us understand how to treat it. I hope to improve this article by:

-In the "Presentation" portion, I will add likely physical exam findings that physicians use to assess the need for more extensive workup

-Under the "Diagnosis" heading, list normal blood work and labs that are performed, as well as what these tests are intended to rule out or rule in

-Addressing re-feeding syndrome and the pathophysiology behind it, most likely under the "Treatment" heading

-I would also like to add some images, particularly one of a normal growth chart and one of a FTT child

-List the "congenital heart defects" most often associated with FTT, as well as TORCH infections

-Add some of the "nonorganic causes" that are missing (ARFID, speech pathology, esophageal dysmotility)

-Address pre- and perinatal conditions that can predispose a child to FTT (poor breast milk production, Low birth weight, intrauterine growth restriction, perinatal stress, and prematurity)

-Discuss "wasting" as a decrease weight in proportion to length vs. "stunting", where height decreases after weight decreases; both are indicative of FTT

-Add a sentence or two about head circumference, and the difference in etiologies in children with decreased weight, length and head circumference vs. children with only decreased weight

-In "Epidemiology", provide some worldwide statistics on FTT to compare and contrast the US vs. Europe vs. World--struggled to find

-In "Treatment" I would like to add the goal growth parameters that define adequate response to treatment. I would also like to address the temporary (usually) measures used to circumvent feeding difficulties in the setting of adequate or near-adequate absorption (G-tubes, NG tubes)

-In "See also" add malnourishment, small for gestational age

Stunting vs wasting
It is also important to differentiate stunting vs. wasting, as they can indicate different causes of FTT. "Wasting" refers to a deceleration in stature more than 2 standard deviations from median weight-for-height, whereas "stunting" is a drop of more than 2 standard deviations from the median height-for-age.

The characteristic pattern seen with children with inadequate nutritional intake is an initial deceleration in weight gain, followed several weeks to months later by a deceleration in stature, and finally a deceleration in head circumference. A decrease in length with a proportional drop in weight can be related to long-standing nutritional factors as well as genetic or endocrine causes. Head circumference, as well, can be an indicator for the etiology of FTT. If head circumference is affected initially in addition to weight or length, other factors are more likely causes than inadequate intake. Some of these include intrauterine infection, teratogens, and some congenital syndromes.


 * 1) 1.	Frank D, Silva M, Needlman R. Failure to thrive: Mystery, myth and method. Contemp Pediatr 1993; 10:114.

Refeeding syndrome
Refeeding syndrome is caused by a shift in fluid and electrolytes in a malnourished person as they receive artificial refeeding. It is potentially fatal, and can occur whether receiving enteral or parenteral nutrition. The most serious and common electrolyte abnormality is hypophosphatemia, although sodium abnormalities are common as well. It can also cause changes in glucose, protein, and fat metabolism. Incidence of refeeding syndrome is high, with one prospective cohort study showing 34% of ICU experienced hypophosphatemia soon after feeding was restarted.

BMJ 2008;336:1495

Hearing SD. Refeeding syndrome. BMJ 2004;328:908-9

Marik PE, Bedigan MK. Refeeding hypophosphataemia in an intensive care unit: a prospective study. Arch Surg 1996;131:1043-7

Diagnosis:
-Observe the child eating a meal, to assess for feeding difficulties.

-Obtain a 3 day food diary, to assess for proper nutrition.

-Assessing the child's stool, taking particular note of the frequency, quantity, and consistency, as well as the fat, blood, or mucus content.

-Initial bloodwork should be based on the clinical picture of the child. Common bloodwork should include a CBC with differential, a complete metabolic panel to look for electrolyte derangements, a thyroid function test, and a urinalysis. If indicated, anti-TTG IgA antibodies can be used to assess for Celiac's disease, and a sweat chloride test is used to screen for cystic fibrosis. If no cause is discovered, a stool examination could be indicated to look for fat or reducing substances. C-reactive protein and erythrocyte sedimentation rate (ESR) can also be used look for signs of inflammation.

https://www-clinicalkey-com.ezproxy-v.musc.edu/#!/content/book/3-s2.0-B9780323530422003163?scrollTo=%23hl0000091

Presentation:
physical exam findings/causes

-hypotension--adrenal or thyroid insufficiency

-hypertension--renal disease

tachycardia/tachypnea--increased metabolic demands

"Physicians look for many signs on physical exam that can indicate a potential cause of FTT. For example, findings such as scaling skin, spoon-shaped nails, cheilosis and neuropathy may indicate potential vitamin and mineral deficiencies. Fetal alcohol syndrome (FAS) has also been associated with FTT, and can present with characteristic findings including microcephaly, short palpebral fissures, a smooth philtrum and a thin vermillion border. Malabsorption, due to disorders like Crohn disease and cystic fibrosis, can present with abdominal distention and hyperactive bowel sounds.

-pallor--anemia

-drooling--oral motor dysfunction

-dysmorphic features--clinical or genetic syndrome associated with poor weight gain

-microcephaly--neurologic disorder, fetal alcohol syndrome

-delayed closure of fontanelle--vitamin D deficiency, hypothyroidism

-short palpebral fissures--fetal alcohol syndrome

-cataracts--congenital infection, galactosemia

-papilledema--increased ICP

-smooth philtrum--FAS

-aphthous stomatitis (Crohn disease)

-Thin vermillion border--FAS

Chest

-wheezing, crackles, prolonged expiratory phase, hyperexpansion--CF, asthma

-heart murmur--congenital heart disease

abdomen

-abdominal distension, hyperactive bowel sounds-malabsorption

-HSM-liver disease, glycogen storage disease, malignancy

GU

-rectal fistulae, large perianal skin tags--Crohn disease

MSK

-clubbing-chronic hypoxia 2/2 cardiac or pulmonary disorders

-bony deformities (craniotabes, scoliosis, bowing of long bones--rickets

-edema--protein deficiency

Neuro

-abnormal deep tendon reflexes-CP

-hypotonia, weakness, spasticity--associated with oral motor dysfunction

-neuropathy--vitamin deficiencies (B12, B3, B6, E)

Skin

-scaling skin--zinc deficiency

-candidiasis--immune deficiency

-spoon-shaped nails--iron deficiency

-cheilosis--vitamin def (B2, B3, B6)

chronic diaper rash--possible neglect

bruises in characteristic patterns--possible abuse


 * 1) 1.	Frank D, Silva M, Needlman R. Failure to thrive: Mystery, myth and method. Contemp Pediatr 1993; 10:114.
 * 2) 2.	American Academy of Pediatrics Committee on Nutrition. Failure to thrive. In: Pediatric Nutrition, 7th ed, Kleinman RE, Greer FR (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2014. p.663.

O'Neil, Erica, "Pre- and Post-natal Growth Deficiencies and Fetal Alcohol Syndrome". Embryo Project Encyclopedia (2011-05-04). ISSN: 1940-5030 http://embryo.asu.edu/handle/10776/2099.