Failure to thrive (FTT) atau Gagal Tumbuh

IKG SuandiDepartment of Pediatrics, School of Medicine

Udayana University/Sanglah Hospital

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Objectives

• Mengetahui definisi dan kriteria pasien dg failure to thrive (FTT) atau gagal tumbuh

• Mengetahui penyebab atau patofisiologi failure to thrive (FTT) atau gagal tumbuh

• Mengetahui cara mencegah atau merujuk pasien dg failure to thrive (FTT) atau gagal tumbuh

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Definition

• Failure to thrive mula-mula pd awal th.1900 dipakai utk menguraikan:– keadaan malnutrisi1 – dan keadaan depresi pd bayi2

• Failure to thrive suatu deskripsi dan bukan menyatakan suatu diagnostik:– pada anak yg BB-nya tidak naik-naik3 – atau peningkatan BB secara bermakna di bawah BB

anak lainnya yg seusia dan berjenis kelamin sama4.

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Table 1. Definitions of Failure To Thrive (FTT)

• Attained growth– Weight < 3rd percentile on NCHS growth chart– Weight for height < 5th percentile on NCHS growth chart– Weight 20% or more below ideal weight for height– Triceps skin fold thickness < 5 mm

• Rate of growth– Depressed rate of weight gain

• < 20 g/d from 0-3 months of age• < 15 g/d from 3-6 months of age

– Fall-off from previously established growth curve• Downward crossing of > 2 major percentiles on NCHS growth chart

– Documented weight loss

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Figure 1. The curve of patient with FTT

Delayed 8 weeks or more

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Figure 2. The curves of patient with FTT

(Weight)

(Height)

(Head circumference)normal

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Etiology(1)

• Faktor-faktor penyebab gagal tumbuh pada bayi dan anak, meliputi:– Penyakit medis yg serius/berat– Disfungsi interaksi antara anak dan pengasuhnya– Kemiskinan – Misinformasi orangtua– Child abuse

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Figure 3. Nonorganic FTT

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Etiology(2)

• Mayoritas kasus penyebabnya bukan penyakit organik; tapi gagal tumbuh sering karena problem psikososial

• Apakah penyebabnya penyakit primer organik atau psikososial anak akan mengalami malnutrisi dg konsekuensi fisik dan psikologik berisiko long-term physical and psycho-developmental squelae.

Etiology(2)Etiology(2)

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Figure 4. Organic etiology (intestinal malrotation)

Abnormal bands

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Figure 5. Pedigree patient with FTT

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Figure 6. Pedigree patient with FTT

Carrier

Unaffected

grand mother or grand father

Carrier grand mother

Unaffected grand father

Unaffected

Unaffected

18 month old Affected

8 year old unaffected

Mr. A Mrs. A

F1 :

F2 :

F3 :

F4 :

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Table 2. Causes of inadequate weight gain

1. Inadequate intake:

Poverty, misperceptions about diet & feeding practices, error in formula

constitution, dysfunctional parent-child interaction, mechanical problems with

suck-swallow-feeding, systemic disease resulting in anorexia/food refusal.

2. Calorie wasting:

Persistent vomiting, mal-absorption and/or chronic diarrhea, renal losses.

3. Increased caloric requirements:

Congenital heart disease, chronic respiratory disease, neoplasm,

hyperthyroidism, chronic or recurrent infection.

4. Altered growth potential/regulation:

prenatal insult, chromosomal abnormality, endocrinopathies.

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Table 3. Factors influencing nutritional inadequacy in the elderly population

Physiologic Pathologic Sociologic Psychologic

Decreased taste Dentition Ability to shop for food Depression

Decreased smell Dysphagia, swallowing problems Ability to prepare food Anxiety

Dysregulation of satiation

Diseases (cancer, CHF, COPD, diabetes, ESRD, thyroid)

Financial status

Low socioeconomic

Loneliness

Delayed gastric emptying

Medication (diuretic, antihypertensive, dopamine agonist, antidepressant, antibiotic, antihistamine)

Impaired activities of daily living skills

Emotionally stressful life events

Decreased gastric acid

Alcoholism Lack of interactions with others at mealtime

Grief

Decreased lean body mass

Dementia Dysphoria

CHF = congestive heart disease; COPD = chronic obstructive pulmonary disease; ESRD = end stage renal disease

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Keys of aspects of the evaluation

• Evaluasi pertumbuhan sekarang dan yg terdahulu:– Riwayat penyakit dan pemeriksaan fisik– Perkembangan / kebiasaan– observasi makanannya– situasi-spesifik dan interaksi global anak-orangtua– Pemeriksaan laboratorium selektif tergantung hasil

pemeriksaan di atas

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Diagnosis(1)

• Bila anak pertumbuhannya buruk fokuskan pada: – Identifikasi gejala dan peny. yg mendasari.– Tingkat beratnya malnutrisi.– Penting mencari tanda-tanda spt. kekerasan fisik

(physical abuse) / terlantar/tidak diinginkan atau tingkah-laku yg menyimpang

• Interaksi orangtua-anak– Perhatikan waktu anak makan cara ini utk

mengidentifikasi tingkah-laku spesifik atau masalah interaksi selama makan.

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Figure 7. Enteropathology of patient with diarrhea and FTT

Abnormal villous & mucosa

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Figure 8. Organic abnormality of a patient with FTT

Abnormal brain

Distended abdomen

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• Perkembangan Psychomotor:– Bila anak gagal tumbuh psikososial berat

manifestasi bermacam-macam dari hyperalert, perhatiannya berlebihan sampai menolak kontak mata dan apathetic withdrawal.

– Beberapa anak manifes perkembangan terhambat, terutama pada area bahasa dan tingkah-laku adaptif sosial tergantung pada stimulasi lingkungan.

Diagnosis Diagnosis(2) Diagnosis(2)

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Figure 9. Patients with FTT

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• Pemeriksaan laboratorium:– Tergantung riwayat penyakit, pem. fisik, data

pertumbuhan, dan peny. organik.

– Studi laboratorium utk menentukan status nutrisi dan masalah anemia defisiensi besi.

– Pemeriksaan Lab.: darah lengkap, serum elektrolit,

serum kreatinin, total protein/albumin, urinalysis, kultur urine, and bone age (bila tinggi badan juga buruk).

Diagnosis(3) Diagnosis(3)

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Management(1)

• Evaluasi dan tatalaksana secara obat-jalan.

• Gagal tumbuh psikososial perlu MRS bila berisiko tinggi, mengalami kekerasan fisik / terlantar, malnutrisi berat atau scr medis tidak stabil, atau tatalaksana obat-jalan mengalami kegagagalan.

• Tatalaksana gagal tumbuh psikososial bersifat individu tergantung kebutuhan spesifik anak dan keluarga.

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• Rehabilitasi nutrisional difokuskan pd upaya mengoreksi:– Interaksi anak-orangtua– Misinformasi orangtua– Tuntunan makanan spesifik– Kebutuhan psikososial keluarga.

• Pendekatan tim multidisiplin:– Meliputi pekerja sukarela / pekerja sosial, nutrisionis,

spesialis perilaku anak, dan community-based outreach services.

Management(2)

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Summary

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