WHAT HAS FAILURE TO THRIVE GOT TO DO WITH NEGLECT ?
Transcript of WHAT HAS FAILURE TO THRIVE GOT TO DO WITH NEGLECT ?
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WEIGHT FALTERING AND
FAILURE TO THRIVE
Charlotte M Wright Professor of Community Child Health
PEACH unit Glasgow University
Hon Consultant Paediatrician Yorkhill
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What causes weight
faltering?
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Non-organic Failure to
Thrive ‘Hospitalism’
Chapin 1915
‘Maternal deprivation’ Bowlby 1973
At risk register category in Scotland and in England till 1989
Associated with 20 point DQ deficit Dowdney 1987
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How do we know what we
know about weight faltering
(failure to thrive )? • British population based studies
– Skuse and colleagues, London 1980s
– Studies on Tyneside • Parkin Project
• Growth and development study
• Gateshead Millennium study
– Avon Longitudinal Study of Parents and
Children (ALSPAC)
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The role of Organic disease in
UK weight faltering
• Fully explains only 5-10% cases in UK population
• May contribute to poor intake in further 10%
• Those with significant organic disease present with symptoms or signs of underlying disease
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Role of maternal deprivation
and neglect in weight faltering
• Almost no relationship (in UK) between poverty and weight gain or failure to thrive
• Weak association with maternal depression
• Most weight faltering children (95%) have no evidence of abuse or neglect
• But abused or neglected children are 5 x more likely to weight falter
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Young babies are all at risk
of undernutrition
• Very high energy requirements
• Weight doubles by age 4m, trebles
by age one year
• To grow normally, newborn infants
must consume 15% of their weight
in milk daily
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Why do babies fail to thrive
in ‘normal’ homes ?
Child factors: • Poor appetite drive or feeding skills
• Minor illnesses
• Undemanding
Maternal factors: • Distracted / depressed / avoiding food
• Dietary mis-match
• Over anxious /over persuading
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Risk Factors for undernutrition
in poorer communities
• Family size
• Non-exclusive breast feeding (<6m)
• Lack of, or low density weaning
foods (>6m)
• Economic pressures to work
outside home
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How should weight faltering
be diagnosed?
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Weight
faltering
2 centile
space fall
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When does a down a centile
chart become abnormal?
• Degree of variation depends upon standard used and initial centile – 5% fell through 2 centile spaces compared to
previous reference (UK 1990)
– <2% children fall through 2 centile spaces compared to WHO
• Centile falls are rarer and more significant in initially small children; common in large children – <9th only 2% children centile will fall one centile
space
– >91st 2% will fall three spaces
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What threshold would work
for Hong Kong?
• Will depends upon
– What growth standard is used
– How healthy children fit to that
standard
– Prevalence of real malnutrition
• Need to test any threshold using
local population based data
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Does a centile fall always
imply malnutrition?
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Wasting <2nd centile for BMI
(UK 1990)
Sustained weight
faltering <5th internal centile for
conditional weight gain since
birth at 2 or more ages
Does a centile fall always imply
malnutrition?
Stunting <2nd centile for length
(UK 1990)
0.6% (5)
4.1% (35) 3.8% (32) 1.8%
(15)
0.4% (3)
0.1% (1) Shorter and
thinner later in
childhood
True
undernutrition
prevalence = 2.3% Data from
Gateshead
Millennium study
38% of those with
weight faltering also
have low BMI or
stunting
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Substantial centile
fall
Measure length
Length
proportionate
to parents
BMI low
(<2nd UK-WHO)
Length low
compared to
parents
Undernutrition
unlikely
Undernutrition
likely
Algorithm for assessing weight faltering
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How should weight faltering
be assessed and managed?
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A staged, proportionate approach to
managing Weight Faltering Weight gain below screening threshold
PH nurse assessment
Dietician assessment
Paediatric assessment
Multidisciplinary discussion
SW referral
Recovering
Recovering
Recovering
Recovering
Psychology
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Weight faltering assessment
in primary care
• Family’s concerns
• Medical History
• Feeding History
• Behaviour / Development
• Family History
• Growth Information
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Dietary assessment in
primary care
• Don’t offer advice without prior
assessment of:
– Food Preparation and purchasing
– Meal Times
– Food Eaten / Drinks
• Food Diary: 3 days
• Witnessed Meal
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Dietetic assessment
• Home visit may be more effective than clinic review
• Assess the adequacy of the current diet to supply essential nutrients – Offer targeted advice about enhancing the
diet
• Advise on – Meal time routine
– Management of basic feeding behavioural problems
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General strategies for dietary
improving intake
• Offer three meals and two snacks
each day at regular times
• Increase variety of foods offered
• Increase energy density of usual
foods
• Limit milk intake to 500 mls per day
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Specialist paediatric
assessment • Indications
– Features suggesting an associated illness
– Significant weight faltering that has persisted despite community and dietetic interventions
• Role – Reassess the growth data
– Exclude organic pathology
– Reinforce dietary advice
• Inpatient monitoring not advisable
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Investigations for sustained
weight faltering
• All children (all at once) – Full blood count, Ferritin
– Urea and electrolytes
– Thyroid function tests
– Mid stream urine
• When indicated – Chromosome analysis (short girls)
– Chest radiograph (respiratory symptoms)
• UK but ? not Hong Kong – Coeliac disease screening
– Sweat test
– Vitamin D levels
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Dangers of medical management of
weight faltering
Appropriate Rx deferred
Irrelevant diagnoses
Energy insufficiency
Weaning further delayed
Pain and distress, risk of long term dependence
Decompensation and death
• Prolonged
investigations
• Exclusion diets
• Supplements
• Tube feeding
• IV feeding
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Interventions
• Targeted dietary advice
• Behaviour management
• Support for family
• Nursery placement • Supplements / artificial feeding (very rarely)
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Clinical psychology input
• Indications
– Pronounced food refusal
– Anxious, stressful mealtimes
• Role
– Meal time video observation • Watch with parents
• Structured supportive feedback
– Working with the parents to control anxiety
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Social work / Child protection input
• Indications – Direct evidence suggesting abuse or neglect
– Persisting weight faltering despite advice plus • Major social problems
• Drug or alcohol abuse
– Weight faltering on its own does not require social work referral
• Role – Work with families to ensure have adequate
resources
– Enable families to access appropriate support
– Legal measure / alternative care: only in extreme cases
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The long term outcome of Weight
Faltering depends upon severity,
duration and cause
Severity of Undernutrition
<2 centile space fall
or transient fall
2-3 centile space fall
> 3 centile space fall
Fall though 5+ centile spaces <70% Weight-for-height
Possible consequences
No consequences
Stunting
Developmental delay
Immune suppression
Permanent IQ loss
Death
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Summary
• Weight faltering (failure to thrive) is common
• Weight faltering + thinness or stunting suggests under-nutrition
• The health visitor (public health nurse) is often best placed to assess and advise in the first instance.
• Organic disease is rare in otherwise asymptomatic children
• Usually responds to simple targeted dietary advice
• Severe, unresponsive cases may require SW or psychology input
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Pathological
undereating
Wasting, stunting
Immune
supression
Developomental
delay
Lack of metabolic
reserve
Pathological
overeating
Very high fat,
raised lean
Bully victim
Reduced mobility
Risk of future
disease
Relative
undereating
Slim
May develop
feeding problems
Parental anxiety
Relative
overeating
Plump
May worry about
weight
May add confidence
Parents not worried
Main age affected
Pre-school Mid childhood Teenage
The Normal Curve for Drive to Eat
Easily sated or
deterred from
eating
Will eat beyond
hunger
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Gateshead’s ultra orthodox
Jewish community
• 3% births in district
• 15% weight faltering cases – Large families
(54% 5+ children)
– Prolonged breastfeeding (37% >12m)
– Late weaning (73% > 4 months)
Weight gain in Ultra orthodox
Jewish Infants in Gateshead
-1.33
-0.67
0.00
0 1.5 4 8 12
Age in months
Weig
ht S
D s
core
s
UOJ
Rest of cohort
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• Prospective population based study of feeding and growth
• Gateshead = urban borough in NE England
• 1029 subjects born to resident mothers
• Recruited shortly after birth June 1999 - May 2000
• 4 questionnaires in first year
• Health check aged 13 months
• Studied in school aged 7-8 (60%)
Gateshead
illennium Study