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Elevated white count – indicates infection or inflammation, immune system disorder, bone marrow disease, reaction to medicineLow H&H – indicates anemia (weakness and fatigue) - caused by blood loss, underlying conditions, low levels of certain vitamins or iron
By month 4-6, children should have doubled their weight from birth. Vs. Familial short stature – child born genetically small, grows at rate parallel to the growth curve, below 5th percentile. Maintains normal weight for height and appropriate skinfold measures.
Long-standing hypothyroidism results in hyperplasia of the thyrotroph cells and subsequent enlargement of the pituitary gland.
The thyroid is a hormonal gland located in the neck. Calcintonin participates in calcium and bone metabolism.
For 3-6 month olds, NCM says expected protein, energy needs: average protein 2.2 g/kg/day + 108 kcal/kg/day
Failure to Thrive: A Case Study
By Emily Todhunter, WVU GDI 2012
Overview of Patient Failure to Thrive Medical Nutrition Therapy for FTT Patient Labs Hypothyroidism Nutrition Assessment of Patient o Nutrition Diagnosis o Nutrition Prescription o Nutrition Intervention o Monitoring/Evaluation
5-month old female Presents with fever and vomiting on 11/5 o Fever at 9:30am of 101.2*F, some improvement after administration of Tylenol but fever then persisted at 102*F Saw pediatrician who referred her to the ER o ER Course: Lab work – elevated white count (18,700) H & H low at 10.1 and 30.5, platelet count 446,000. Urine lab normal. o ER Treatment: Dose of Rocephin (injection used to treat bacterial infections – Ceftriaxone) o ER Diagnosis: 1) Acute febrile illness, viral syndrome, rule out bacteremia 2) Failure to thrive
Full-term vaginal delivery, birth weight 7 # 13 oz At 2 months and 1 week old, mother went back to work Milk production decreased, mother couldn’t pump as often Baby doesn’t sit up independently Baby attends daycare during day Mother states child vomits after consuming more than 3.5 oz in one sitting Mother states that baby has been developing okay as far as length and head circumference but her weight gain has been poor Currently weighs 10 # 10 oz
Physical sign of undernutrition, characterized by growth rates that do not meet expected standards for infants and toddlers under 3 years of age Inadequate nutrition for optimal growth Seen in 5-10% of US children in primary care settings Possible causes of FTT in children include: o Inadequate energy intake o Inadequate nutrient absorption o Increased metabolic demands o Defective nutrient utilization
Increased risk for growth deficiency or short stature Increased susceptibility to childhood diseases May be at increased risk for later heart disease Under-nutrition during critical brain development causes retardation of brain growth as well as a variety of functional abnormalities in the neurons
Organic FTT o Associated with a chronic disease process or disability o Conditions that affect digestion or absorption o Examples: GERD (energy intake), chronic diarrhea (nutrient absorption), cerebral palsy (metabolic demands), chromosomal abnormalities (nutrient utilization) Nonorganic FTT o Term used to describe poor growth of a child in the absence of any medical diagnosis o Largely environmental o Commonly associated with delayed development, abnormal behavior, altered infant-caregiver interaction.
Most often multi-factorial. o Psychosocial o Environmental o Biological Example: o GERD child upset during feeding times due to pain of acid reflux caregivers interpret reaction as cue to stop feeding o GERD (organic) + Infrequent/inadequate feedings (nonorganic)
Weight for age is less than 5th percentile on a standard WHO growth chart (0-24 months) or CDC growth chart (24+ months), with normal height/length Weight for length less than then 5th percentile (0-24 months) on a standard WHO growth chart and/or BMI (24+ months) is less than the 5th percentile on a standard CDC growth chart Weight is less than 80% of expected weight for height/length Deceleration of growth velocity across two major percentile lines and/or decrease of more than 2 SDs on a CDC or WHO growth chart over a period of 3-6 months
Child at or above 50th percentile for length both at birth and 5 months of age Child born at 50th percentile for weight, but has dropped to below the 5th percentile for weight by 5 months of age o Birth: 51.4 cm, 3.55 kg o 5 Months: 63.5 cm, 5.06 kg
By month 4-6, child should have doubled their birthweight Healthy weight gain from 0-6 months is 5-7 oz/week (or 140-200 g/week) This child gained an average of 2 oz/week (68 g/week) from birth to 5 months.
Provide adequate nutrients and energy for appropriate weight gain and linear growth for age Reinforcement of nutrition instruction to caregivers For 3-6 month old, monitor weight and length/height weekly until weight gain commences Continue to plot on growth charts every 3 months until child demonstrates acceptable growth curve Enteral nutritional support, if necessaryAge Average Average Average Average Fluid Weight Gain Protein Energy (mL/kg/day) (g/day) (g/kg/day) (kcal/kg/day)3-6 months 15-25 2.2 108 125-160
11/5 11/7 11/8WBC (4.3-15.2 K/cu mm) 18.7 (H) 14.0 11.6 ↑ due to febrile illnessRBC (3.7-5.42 M/cu mm) 3.29 (L) 3.08 (L) 3.23 (L) Slightly ↓ : MalnutritionHgb (10.5-14.1 gm/dL) 10.1 (L) 9.4 (L) 9.7 (L) Blood draws OtherHct (31.5-42.4 % volume) 30.5 (L) 28.0 (L) 29.3 (L)MCV (72-91 fL) 93 (H) 91 91 (Measurement of the average sizeMean Corpuscular of red blood cells)Volume ↑ in hypothyroidism
Hema Miscellaneous 11/8Reticulocyte Count 1.9 (H?) A measure of how many RBCs called(0.5-1.5%) reticulocytes are made by the bone marrow and released into the blood. Retic count rises when there is a lot ofChildren: 0.5-2.0% blood loss or in certain diseases where RBCs are destroyed prematurely.
Prealbumin: 9.0 mg/dL on 11/6 “Normal Range” = 20-40 mg/dL Best indicator for malnutrition we have available, as albumin levels were not tested. Indicates protein-malnutrition. Age Normal Lab Value 0-6 months 7-39 mg/dL 7-36 months 2-36 mg/dL 4-6 years 12-30 mg/dL 7-19 years 19-35 mg/dL Pediatric Nutrition Care Manual
11/6Free Thyroxine (0.9-1.8 ng/dL) 0.6 (L)TSH (0.4-6.0 μIU/mL) 1.957 MD consult for low free T4 (11/8) Initiated a 1 mcg ACTH stimulation test and she had a peak cortisol level of 53.3 which was normal. Prolactin level was 7.9. She had a serum osmolality of 279. The urine osmolality of 358. “They went ahead and did a MRI of the pituitary. The radiologist did read this as normal however, when we reviewed the MRI images ourselves, we felt that the pituitary did appear to be hyperplastic.”
Non neo-plastic increase in one or more functionally distinct types of pituitary cells Pituitary enlargement is induced by the lack of T4 feedback and has been reported to revert on thyroid hormone replacement The incidence of pituitary hyperplasia in patients with hypothyroidism varies from 25% to 81% Thyroid hormone replacement therapy led to a decrease in the size of the gland in 85% of patients with pituitary enlargement who underwent follow-up MR examinations Pituitary Gland
Assessment: 1) Central hypothyroidism 2) FTT 3) Question of an abnormal pituitary MRI Plan: “Continue her on Synthroid 25 mcg, which she started. She does have a growth factors are pending. I advised the mother that we would see her back in the office in about 1-2 weeks after discharge. We will follow w/ her clinically after that.”
Produces thyroid hormones triiodothyronine (T3) and tetraiodothyronine, or thyroxine (T4) and Calcintonin Hormones regulate metabolism, growth and maturation of human body Production of thyroid hormones is regulated by the pituitary gland (which produces TSH – thyroid stimulating hormone)
Condition in which the thyroid does not make enough thyroid hormone. o Low free T3, T4 in the blood o High TSH Symptoms include: lack of energy, depression, constipation, slowed metabolism, weight gain, hair loss, dry skin, dry coarse hair, muscle cramps, decreased concentration, aches and pains, swelling of the legs, and increased sensitivity to cold
Lack of these hormones early in life can have severe effects on a baby or child’s physical, intellectual, and emotional development Will need life-long therapy Doctor may check thyroid levels every 2-3 months at first Re-check thyroid levels every year Energy restriction produces a transient, hypothyroid, hypometabolic state that normalizes on return to energy- balanced conditions (Weinsier et al., 2000)
In children, initial dose of 25 mcg/day of levothyroxine sodium is recommended with increments of 25 mcg every 2-4 weeks until the desired effect is achieved. For 3-6 months of age, recommended 8-10 mcg/kg/day o For 5.06 kg, about 40-50 mcg/day Peak therapeutic effect may not appear until 4-6 weeks after initiation of therapy (due to long half-life)
2 T x 2 whole wheat cereal 2 x 30 minutes of breast feeding 11 oz of 24 cal/oz formula (3.5 oz, 3.5 oz, 4 oz) = 315 calories (cereal & formula) + 60 minutes of breast feeding According to NCM, typical portion sizes & daily intake for infants 4-6 months: o Breast milk or infant formula (6-8 oz) x 4-6 feedings/day o Infant cereal (1-2 Tbsp) x 1-2 feedings/day
11/6 o Daily Total Calories: 315 (+ 60 min breast feeding) o 43.5% of estimated needs o Providing 65 kcal/kg 11/7 o Daily Total Calories: 610 o 84.3% of estimated needs “Pt’s intake improved yesterday (11/7), however, mom’s record and documented intake vary. Discussed plan w/ resident, will continue w/ current formula. May consider further concentrating formula. Await endocrinology lab results.”
“May consider asking mom to pump, add HMF or powdered formula to expressed mother’s milk. May also consider 27 cal/oz formula if pt. unable to consume more volume/feed.” HMF: Human Milk Fortifier o Mixed with measured amounts of human milk to provide an extra 2-4 calories/ounce (1 pkt to either 25 mL or 50 mL of human milk)
Secondary to: Admitting Diagnosis (FTT); Prealbumin <16 (9) Current Medical History: FTT, Febrile, Vomiting Braden score = 25 No IV Medications: Tylenol Nutrition Therapy Order: Regular (lactating), infant formula 4 oz every 3-4 hours Similac Sensitive_22 calories every 3 hours, 2 Tbs cereal BID IBW/ht IBW/age Wt/Ag Ht/Age Wt/HtLength Weight IBW %IB W e % % %63.5 cm 5.06 kg 6.7 kg 76% 6.6 kg 2 months <3rd 50th <3rd
D5 NS @ 50 mL/hour over 20H o 11/5 o 170 calories dextrose KCl 10 mEq in D5/NACL 0.225% (1000 mL bag) IV @ 15 mL/hr over 24 hrs o 11/6, 11/7, 11/8 o 61.2 calories dextrose/day
Estimated energy needs: 527-724 calories (108-143/kg) o 108 x 5.06 = 527 o 108 x 6.7 = 724 o 724/5.06 = 143 Estimated protein needs: 11-15 g (2.2-2.9/kg) o 2.2 x 5.06 = 11 o 2.2 x 6.7 = 15 o 15/5.06 = 2.9 Fluid: Per MD Nutritional Risk: Mod/High f/u 5-7 days
Underweight related to failure to thrive asevidenced by 76% ideal body weight and <3rd percentile weight for height.
Nutritional Goals: o Improve protein status o Adequate intake o Tolerate P.O. diet o Promote weight gain Nutritional Interventions: o Calorie count o Encourage P.O. intake o IPOC o Will monitor wt, labs, and p.o. intake Notes: The current nutrition order provides 134 kcal/kg on current weight (5.06 kg BW)
Similac Sensitive formula (for gas/fussiness) since 3 months of age In 100 calories of formula: o %calories from carbohydrates: 43 o %calories from fat: 49 o %calories from protein: 9
11/5 11/6 11/7 11/8 11/9 11/9 17:47 00:04 06:16 06:00 06:00 11:48Weight in 4.82 5.06 4.94 4.88 5.94 4.92kg Expected weight gain for children 3-6 months old: 15-25 g/day (NCM)
http://www.cdc.gov/growthcharts/ http://www.mayoclinic.com/ http://www.nlm.nih.gov/medlineplus/ency/article/003696.htm http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682461.html Pediatric Nutrition Care Manual – Academy of Nutrition and Dietetics Cole, S. Z., & Lanham, J. S. (2011). Failure to thrive: An update. American Family Physician, 83(7), 829-834. Retrieved from http://www.aafp.org/afp/2011/0401/p829.html Franceschi, R., Rozzanigo, U., Failo, R., Bellizzi, M., & Di Palma, A. (2011). Pituitary hyperplasia secondary to acquired hypothyroidism: case report. Italian Journal of Pediatrics, 37(15), doi: 10.1186/1824-7288-37-15 Passeri, E., Tufano, A., Locatelli, M., Lania, A. G., Ambrosi, B., & Corbetta, S. (2011). Large pituitary hyperplasia in severe primary hypothyroidism. The Journal of Clinical Endocrinology & Metabolism, 96(1), 22-23. doi: 10.1210/jc.2010- 2011 Weinsier, R. L., Nagy, T. R., Hunter, G. R., Darnell, B. E., Hensrud, D. D., & Weiss, H. L. (2000). Do adaptive changes in metabolic rate favor weight regain in weight- reduced individuals? an examination of the set-point theory. The American Journal of Clinical Nutrition, 72(5), 1088-1094. Retrieved from http://ajcn.nutrition.org/content/72/5/1088.long