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Approching children with poor weight gain.pptx
- 1. Approaching children with poor weight gain DRFADHLY SHARIMAN BIN HJ YAHAYA HOSPITAL PORT DICKSON
- 2. Case base discussions Approachingchildren with poor weight gain Dr Fadhly Shariman Malaysia - Ireland Training for Family Medicine (MInTFM) Supervised by Dr Aina Mariana Binti Manaf 08/05/2023
- 3. Case Study (28/02/2023) NAME :B/OALINA AMELIA BINTI ABDUL RAHMAN AGE : 1 months 13 days DOB : 15/01/2023 Birth hx : Term 39 weeks 5 day , SVD Birth weight : 3.13kg length 48 cm COH 32 cm Issues : Poor weight gain
- 4. Referral from KlinikKesihatan Poor weight gain Birth History: BW: 3.13kg Length:48cm COH: 32cm Apgar score:9 at 1 min, 10 at 5 min G6PD: normal CTSH: 4.873 Born term at 39 weeks 5 days via SVD ANC 1. Maternal morbid obesity booking bmi 36 latest bmi 40 ECHO : Normal 2. 1 previous scar with 1 successful VBAC 3. Poor spacing 4. GBS positive HVS C&S on 30/11/2022 Given stat dose of IV Cpen (less than 10 minutes prior delivery) No PROM
- 5. Birth history Born termSVD at 39 weeks 5 days, vigorous Antenatally, mother GBS carrier with inadequate antibiotic coverage prior to delivery Postnatal baby was admitted to our SCN in view of infant of GBS mother with inadequate coverage and was subsequently covered for presumed sepsis in view of early onset jaundice with high retic count. However she was prematurely discharged parents insisted persistently on bringing the baby back home despite advice on risk and complications to baby.
- 6. Noted during medicalcheck up in 1 month old at KK weight only 3.05kg ( 2.5% ) weight loss repeat weight 3.13kg mother claim previously on lactogen , 4oz 3 hourly had loose stools for the past 1/52 tca 2 weeks for weight monitoring at KK Noted weight 2.85kg ( 8.94% ) weight loss Refer to hospital for poor weight gain
- 7. Current weight 3.01kg( 1 month 13 days ) Rp : Urea 3.0 / sodium 135 / K 2.8 / chloride 107 / Creat 17 FBC : rejected mother claim diarrhoea for 1/52 frequent changes pampers, watery stools improving initially given lactogen Dutch baby and s26 Frequent loose stools currently similac soya for 5 days 3oz 3 hourly – loose stools improving
- 8. otherwise no trauma no fever novomiting no rapid breathing no sick contact no recently travel o/e sleeping, warm periphery, CRT<2sec Lung : good breath sound a/e equal p/a soft no mass palpable weight gain 5% weight for age : below 3rd centile length for age : below 3 centile
- 9. plan continue similac soyafor now TCA in 6/52 to review back weight and growth KIV to expose baby for cow milk if patient weight gain well
- 10. 13/03/2023 ED HPD c/o: fever for2/7 reduced oral intake and activity for 2/7 rapid breathing x1/7. There is a history of ill contact with her sibling at home.
- 11. upon presentation: severedehydration in hypovolemic shock - lethargic and limp, poor pulse volume, poor perfusion CRT=3s, sunken eyes, sunken anterior fontanelle, crying with no tears with poor skin turgor. Tachypnoeic with acidotic breathing. HR was 150bpm BP wide pulse pressure 80/36mmHg Saturation 97% under RA. Glucose stat 5.3mmol/l severe metabolic acidosis on VBG - pH 6.89, pCO219, pO2 34 HCO3 3.6, BE - 29.5, Lac 1.3
- 12. Patient intubated inview of the severe metabolic acidosis. Clinically patient sedated, pink, good pulse volume, central and peripheral perfusion good Anterior fontanelle normotensive. Eyes still sunken, skin turgor slow +Acidotic breathing
- 13. Physical assessment PO2 97%ventilator PIP 14/6, rate 40, fio2 100% Lungs : breath sounds good and equal, clear CVS : DRNM PA : soft, not distended, hepatomegaly 4cm, no splenomegaly, BS active Bilateral femoral pulses palpable Normal female genitalia Severe perianal excoriation Multiple fungal skin lesions seen all over the face, trunk and limbs
- 14. Investigations Investigations : FBC: TWC:32.2 (Lym: 38.8 Neut: 41.9) Hb 11.9 PLT 811 LFT:T. protein 87 Alb 45 Glo 42 ALT 47 ALP 373 T.bili 17.2 RP: Urea 4.6 Na 120 K 4.2 Cl 110 Creatinine 32 Pre intubation VBG: pH 6.89 HCO3 3.6 Lac 1.5 Glu 5.3 pCO2 19 pO2 34 Post bolus VBG: pH 6.87 HCO3 < 3.0 Glu 8.7 Lac 1.5 pCO2 13 pO2 65 Repeat VBG: pH 6.87 HCO3 3.7 Lac 2.2 pCO2 20 pO2 36 Post intubation ABG: pH 6.80 HCO3 5.8 BE -28.1 pCO2 37 pO2 442 (under fio2: 100%)
- 15. Management plan Plan: IVD HSD5%full maintenance at 18.8cc/hr IVD correction 10% NS run at 25cc/hr over 12 hrs(start at 8pm) IVI morphine 3mg in 50cc D5% run 1ml/hr (20mcg/kg/hr) IV Cefotaxime 150mg STAT given at 9pm (50 mg/kg) Transfer out to HTJS for ventilator support and further management
- 16.
- 17. Key points • Optimalgrowth assessment requires serial measurements plotted on appropriate growth charts • Nutrition is the main driver of growth in children under 2 years of age. Most cases of slow weight gain are secondary to inadequate caloric intake • Slow weight gain is commonly multifactorial in origin, with psychosocial stressors often a significant contributor • Small and otherwise healthy babies following a growth percentile line may not need any investigations
- 18. IDENTIFY NORMAL GROWTH PATTERNIN AN INFANT
- 19. WEIGHT • Lose 10-15%of their birth weight in first 7-10 days of life due to: I. Excretion of excess extravascular fluid II. Possibly poor intake (intake improves as colostrum is replaced by higher fat milk, as infant learn to latch on and suck more efficiently, and as mother become more comfortable with feeding technique) • 1st 3months of life, rate of weight gain 25g/day Babies usually regain their birth weight by 2nd week • Double birth weight by 5 month age • Triple birth weight by 1 year of age • Weight estimation for children infant (age in months x 0.5 )+4 children 1-10 years (Age in yr +4) x 2
- 20. © 2010 RoyalCollege of Paediatrics and Child Health www.growthcharts.rcpch.ac.uk Measuring and plotting Measuring Weight Babies should be weighed without any clothes or nappy Children older than two years can be weighed in vest and pants, but no shoes, footwear, and dolls or teddies in hand Only class III clinical electronic scales in metric setting should be used Class III Clinical Electronic Scales
- 21. HEAD CIRCUMFERENCE • AtBirth - 13.5 inches (35 cm) • rate of growth in preterm infant is 1cm/week but reduce with age. head growth follow that of term infant when chronological age reach term • COH increase 12 cm in 1st year of life (6 cm 1st 3 months, 3cm in second 3 months and 3 cm in last 6 months) • 5-12 y 0.33cm/year
- 22. © 2010 RoyalCollege of Paediatrics and Child Health www.growthcharts.rcpch.ac.uk Measuring and plotting Measuring Head Circumference Head circumference should be measured using a narrow plastic or disposable paper tape Measurement should be taken where the head circumference is widest
- 23. LENGTH • Preterm infants= average 0.8- 1.0cm/week. • Term infants = average 0.69- 0.75cm/week. Age Length Birth 50cm 6 months 68cm 1 year 75cm 3 years 90cm 4 years Double birth length (100cm) 5 – 12 years 5 cm yearly
- 24. © 2010 RoyalCollege of Paediatrics and Child Health www.growthcharts.rcpch.ac.uk Measuring and plotting Measuring Length Measure length before age 2 years if concerned. Length should be measured without nappy or footwear. Use proper equipment (length board or mat) as any other method is too inaccurate. Requires two measurers
- 25. THE CAUSES OFFAILURE TO THRIVE IN AN INFANT
- 26. DEFINITION Given to malnourished infants& young children who fail to meet expected standards of growth : Fails to gains weight / length / head size / development. Related to organic, environment and psychosocial causes. Nelson, essential of Peadiatrics, 6th edition.
- 27. DEFINITION Suboptimal weight gainin infants and toddlers Inadequate weight gain when plotted on a centile chart Mild FTT – Fall across 2 centile lines Severe FTT – Fall across 3 centile lines Illustrated textbook of peadiatrics, 4th edition
- 28. DIAGNOSED BY: Weight thatfalls or remains below the third percentile for age OR Weight that decreases, crossing two major percentile lines on the growth chart over time OR Weight that is less than 80% of the median weight for the height of the child Nelson, essential of Peadiatrics, 6th edition.
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- 30.
- 31. Organic Causes Impaired Suck/Swallow Oromotor Dysfunction Neurological Dysfunction eg CerebralPalsy Mechanical feeding difficulty Cleft Palate/cleft lip Chronic illness leading to anorexia Crohn’s Disease Chronic Renal Failure Illnesses that increase metabolic demands Liver Disease Organic Causes: caused by an underlying medical disorder.
- 32. Non-organic Causes Inadequate availabilityof food Feeding Problem—Insufficient breast milk or poor technique or ineffective latching, incorrect preparation of formula Insufficient or unsuitable food offered Lack of regular feeding time Infant difficult to feed Conflict over feeding, intolerance of normal feeding behavior- eg throwing food around or messiness Problem with budgeting, shopping, cooking food, famine Low socioeconomic status Psychosocial Deprivation Poor maternal- infant interaction Maternal depression Poor maternal education Neglect or Child Abuse Factitious illness Non-organic Causes: associated with broad spectrum of psychosocial and environmental deprivation
- 33. • Vomiting • SevereGastro esophageal reflux INADEQUATE RETENTION •IDA •biliary atresia •Coeliac Disease •irritable bowel syndrome •Cystic Fibrosis •Cow’s milk protein intolerance •Short Gut Syndrome •Post Necrotizing Enterocolitis, NEC MALABSORPTION •Chromosomal disorders (eg: Down Syndrome) •IUGR •Congenital infection •Metabolic disorder (congenital hypothyroidism, storage disorders, amino- and organic acid disorder) FAILURE TO UTILISE NUTRIENT • Thyrotoxicosis • Cystic fibrosis • Malignancy • Chronic infection(HIV, Immune deficiency,TB) • chronic lung disease • Congenital heart disease • Chronic renal failure INCREASED REQUIREMENT
- 34. DEMONSTRATE THE IMPORTANCE OFA FEEDING HISTORY
- 35. The importance ofa feeding history • To know the current nutritional intake • To provide the better look at correlating the infant’s development with the types of food offered. • To assess the adequacy of nutritional intake for growth. • To screen for undernutrition or nutritional deficiency. • To detect the causes of undernutrition and exclude other causes of FTT • Planning of management
- 36.
- 37. Breastfeeding history History Comments 1.Ask if the baby is breast fed or bottled fed •Full term newborn babies can obtain all the nutritional needs from breast milk in their first 4-6 months (only breastmilk can supply the secretory Ig A, lactoferrin, peroxidase, lysozyme). 2. The duration of exclusive breastfeeding and mixed breastfeeding Exclusive breastfeeding reduces infant mortality due to common childhood illnesses such as diarrhoea or pneumonia, and helps for a quicker recovery during illness. 3. Frequency per day Demand or timed Well term babies should be given breast feed on demand. (usually 8-12 times/day) 4. Strength of sucking Good sucking reflex means that the baby is well. Otherwise baby may be too weak to suck. 5. Any difficulty in breastfeeding The common reasons to quit breastfeeding are: Low milk production Mastitis Flat or inverted nipples Sore nipples
- 38. Formula feeding history HistoryComments 1. Type of formula Infant, special, soy formula 2. The amount and frequency of milk intake 1 oz= 30mls The milk requirement Day 1: 60mls/kg/day Day 2-3: 90mls/kg/day Day 4-6: 120mls/kg/day Day 7 onwards: 150mls/kg/day 3. Preparation of feeds and hygiene Bottle sterilization, water source 4. Who feeds the baby Placement of the infant for feeding
- 39. Weaning History Comments 1. Askabout weaning and when did the weaning start. Food is needed after 6 months of age in addition to milk to satisfy the increasing energy demands of the infant. However, babies should not be started on foods other than milk before they are 4 months old as their kidneys and digestive system are not fully developed. 2. The types of solid food introduced Normally cereals are introduced and mix with food such as stewed fruits, mashed banana and pumpkin. Gradually, at around 8 months, an eating pattern of 3 meals a day should emerge. The type and quantity of food taken for breakfast, lunch and dinner should be obtained to quantify total calorie intake. 3. Ask about the feeding pattern (Abnormal feeding pattern can cause malnutrition) Refusal (selective to mode of feeding or to a specific parent or selective for some types of food) Fixation (willingness to ingest only 1 type of food/texture of food)
- 40.
- 41. INTRODUCTION 1. Nutrient needsdetermined by: Body size Growth rate Age 2. A child’s requirement is higher than an adult’s. 3. Nutritional deficiency are more commonly seen in infancy as young children have fewer body reserves of all nutrients.
- 43. Source: National CoordinatingCommittee on Food and Nutrition (2005)
- 44. Recommended Nutrient Intake(RNI) 1. RNI for children do not differ for boys and girls except for energy. 2. All RNI values has a margin of safety except for energy 3. RNI for most nutrients is higher than physiological needs of most children. 4. If nutrient intake of a child less than RNI, it does not necessarily mean child has nutritional problem.
- 45. Nutrient Recommendations • Basedon Malaysian Dietary Guideline (MDG) 2010: Key message 12: Practice exclusively breastfeeding from birth until six months and continue to breastfeed until two years of age.
- 46. Key recommendations: • Preparefor breastfeeding during pregnancy • Initiate breastfeeding within one hour of birth • Breastfeed frequently and on demand • Give only breast milk to baby below six months with no additional fluid or food • Continues to give babies breast milk even if baby is not with the mother • Introduce complementary foods to baby beginning at six months of age • Lactating mothers should get plenty of rest, adequate food and drink to maintain health • Husbands and family members should provide full support to lactating mothers
- 47. Cereal Products andTubers group
- 48.
- 49.
- 50. Fish, Poultry, Meatand Egg
- 51. Fish, Poultry, Meatand Egg(2)
- 52.
- 53. FORMULATE THE APPROACH TOMANAGEMENT OF A CHILD WITH FAILURE TO THRIVE
- 54. Calories required forcatch-up • Children with failure to thrive require 150% of Recommended Daily Requirement of calories • Schedule: Replacement calories needed per day for malnourished and catabolic infant Age 0-6 months: 130-150 KCal/kg/day (high) 150-220 KCal/kg/day (very high)
- 55. ORGANIC FAILURE TOTHRIVE Treat underlying medical condition Caloric supplementation • Depend on severity and underlying medical problems. • The responds depends on : (Specific diagnosis, medical management, severity of the failure to thrive.) Monitor amount of protein • In children with renal failure
- 56. NON ORGANIC FAILURETO THRIVE Home visit - By health visitor - Assess eating behavior - Provide support Direct practical advice following observation Paeds dietician - Assess quantity & composition of food intake - Recommend strategies to increase E intake Speech & language therapist - Feeding disorder therapy Clinical psychologist & social services Nursery placement - Alleviate stress at home - Assist feeding
- 57. Solid food ->liquid Environmental distraction minimized Eat with other people Not force-fed Rule of 3 : 3 meals, 3 snacks, 3 choices
- 58. Limit intake of: • water • juice • soda • low-calorie beverages Emphasize intake of : high-calorie foods – • peanut butter • whole milk • cheese • dried foods High-calorie supplementation : • Duocal • Polycose High-calorie liquids : • Carnation Instant breakfast with whole milk • Formulas containing >20cal/oz – Pediasure, Ensure, Resource
- 59. Base on case SevereFailure to thrive – Fall across 3 centile line Diagnose Weight that falls or remains below the third percentile for age
- 60. Weight 1st 3months oflife, rate of weight gain 25g/day Babies usually regain their birth weight by 2nd week Double birth weight by 5 month age Triple birth weight by 1 year of age Weight estimation for children infant (age in months x 0.5 )+4 children 1-10 years (Age in yr +4) x 2 ---------------------------------------------------------------------------------- Base on case ( 1 month old x 0.5 ) + 4 = 4.5kg Rate of weight gain 25g/day
- 61. Failure to thrive NonOrganic Feeding Problem - Insufficient breast milk or poor technique or ineffective latching, incorrect preparation of formula Malabsorption • Cow’s milk protein intolerance
- 62. Breastfeeding history History Comments 1.Ask if the baby is breast fed or bottled fed •Full term newborn babies can obtain all the nutritional needs from breast milk in their first 4-6 months (only breastmilk can supply the secretory Ig A, lactoferrin, peroxidase, lysozyme). 2. The duration of exclusive breastfeeding and mixed breastfeeding Exclusive breastfeeding reduces infant mortality due to common childhood illnesses such as diarrhoea or pneumonia, and helps for a quicker recovery during illness. 3. Frequency per day Demand or timed Well term babies should be given breast feed on demand. (usually 8-12 times/day) 4. Strength of sucking Good sucking reflex means that the baby is well. Otherwise baby may be too weak to suck. 5. Any difficulty in breastfeeding The common reasons to quit breastfeeding are: Low milk production Mastitis Flat or inverted nipples Sore nipples
- 63. Formula feeding history HistoryComments 1. Type of formula Infant, special, soy formula 2. The amount and frequency of milk intake 1 oz= 30mls The milk requirement Day 1: 60mls/kg/day Day 2-3: 90mls/kg/day Day 4-6: 120mls/kg/day Day 7 onwards: 150mls/kg/day 3. Preparation of feeds and hygiene Bottle sterilization, water source 4. Who feeds the baby Placement of the infant for feeding
- 64. Reference The Royal ChildrenHospital Melbourne, clinical practise guideline Royal College Paediatrician child and Heath Nelson Essentials of Pedriatic 6th edition Illustrated textbook pf pedriatic 4t edition National Coordinating committee food and nutrition Malaysia Dietary Guideline Malaysia Dietary Guideline,national coordinating committee for food and nutrition
- 65.