hyperactive children) and systemic steroids which can ... tual stimulation of the child as well as the family's ... the height suggests achondroplasia or some other ...
J. M. G. Mawdsley R. G. Chaytors G. L. Higgins
Failure to Thrive: An Approach to Management SUMMARY The family physician is often confronted with the problem of failure to thrive. The possible causes are numerous and diverse, so there is a tendency to attack the problem with a battery of expensive and sometimes unnecessary investigations, which serve only to upset the patient and contribute to the rising costs of health care. The use of a simple organized approach allows common
diagnoses to be made with a minimum of costly investigations. In more complicated cases the use of this plan allows the family physician to pursue the investigation further, narrowing down the diagnostic possibilities before a consultation is required. (Can Fam Physician 1980; 26:1569-1572). .
An exhaustive, expensive investiga- Cushing's syndrome.1 A detailed birth- '' Mr. Mawdsley is a medical student at the University of Alberta tion could be performed, attempting to history is important, including materrule out all possible causes, but it is nal drug and alcohol intake, weight; Medical School. Dr. Chaytors is much more appropriate to use a logical gain, smoking and health during pregassistant professor of family approach avoiding unneces- nancy.3 The gestational age,4 compliorderly is Dr. and Higgins medicine, sary investigations. The most common cations during labor and delivery, and director of the Division of Family Medicine, both at the University of diagnoses lend themselves to confir- the health of the infant during the mation using only a few simple inves- neonatal period are also important. Alberta. Reprint requests to: University of Alberta Family Clinic, tigations. With more complicated Record developmental milestonescases, the differential diagnosis can reached, as well as thorough dietary Royal Alexandra Hospital, still be narrowed down to a small history. Check for feeding problems Edmonton, AB. T5H 3V9. number of possibilities before a con- such as disorders of chewing or swalsultation is sought. A plan like this lowing, easy tiring during feeding or saves time, money and unnecessary chronic vomiting. Ask about stool -frestress to both child and parents. A fur- quency and character, then make a ther advantage is that the deeper insystems enquiry. Evaluate FAILURE TO THRIVE is defined volvement of the family physician in thorough the home for emotional and intellec-' as height and/or weight less than the management of these cases im- tual stimulation of the child as well as two standard deviations below the proves the continuity of their care. The the family's economic status. mean (below the 3rd percentile) or a to diagnosis outlined here approach marked deceleration in growth veloc- (Figure 1) represents a compilation of ity.1 It is a major concern for both pa- some of the methods described in the Physical Examination A system by system examination tients and their parents. It can only be recent literature. should keep in mind the following of the detected by regular recording points. An elevated blood pressure height and weight (plus head circum- History may reveal renal disease.4 Various' ference until age three) during every Previous heights, weights and head genetic disorders may show up as abpediatric office visit. The recumbant length is the most accurate measure of circumferences should be plotted on normalities of facies, external ears, height until five years of age2 and the growth charts and growth velocity fingers, body shape, etc. Examine the standing height thereafter. This data charts. The heights and onset of pu- genitalia and note the stage of sexual should all -be plotted on appropriate berty in siblings, parents and grand- development. An arm span less than growth and growth velocity charts, so parents should also be noted. Current the height suggests achondroplasia or that growth problems become clearly and past medications should be noted, some other skeletal dysplasia. In this particularly methylphenidate (used in case X-rays of the long bones can be apparent. The differential diagnosis of failure hyperactive children) and systemic used to help make the diagnosis.3 Into thrive (Table 1) is long and varied. steroids which can result in iatrogenic adequate parenting may be demonCAN. FAM. PHYSICIAN Vol.
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strated by dirty nails, diaper rash, skin infection or a bald spot on the occiput.5 Finally, a simple assessment of the child's intelligence should be performed.
feeding in the hospital with a carefully to thrive.4 No further investigation is monitored diet and lots of care and at- necessary6 and therapy has begun even tention from the nursing staff is very before the diagnosis is made. Continuuseful here. The child's requirements ing therapy would involve parental for fluids, calories and protein are cal- counselling using the skills of a social culated with the help of a nutritionist worker, dietician and community and daily intake and body weights are nurse if available. If the situation Initial Lab Work recorded.5 It is important for the staff proves hopeless, placement in a foster Only very basic lab work is required to observe and record the interaction would have to be considered.1 initially. A CBC, ESR and urinalysis between parent and child. This usually home 2. Adequate intake but childfails to should be performed.6 An SMA-6 requires four days to two weeks of gain. (electrolytes, BUN and glucose) and hospitalization, depending on the age With a child in this group, the phystools for culture, 0 and P, pH and re- of the child and can take place in the sician should consider malabsorption, ducing substances are inexpensive smallest of community hospitals with- chronic infection, neoplasin, and tests that could speed the diagnosis.5 out special X-rays or lab tests. All that chronic allergies.6 Chronic diseases in is required is a nursing staff that can general can slow growth due to inA. The child with reduced weight, observe the interactions between the creased catabolism of tissues, innormal or slightly reduced height, parents and their child, provide good creased caloric demands, increased and normal or slightly reduced head feeding and mothering and act as role waste or defective metabolism.4 Furcircumference. models and instructors for the parents ther investigation depends partly on In general children in this group do as far as feeding and holding are con- the history, physical and initial lab not receive enough nutrition for their cerned.6 work, but tests to be considered inlevel of metabolism.6 Their malnutriThere are three possible outcomes clude nasal smear for eosinophils, tion may be due to inadequate intake of the hospitalization: chest X-ray, TB skin test, EKG, 72 hour stool fat, xylose tolerance test, 1. Child gains adequately. (economic or emotional deprivation, This suggests inadequate intake sec- sweat chloride, jejunal biopsy, liver feeding problems), maldigestion (cystic fibrosis), malabsorption (celiac ondary to maternal deprivation, eco- function studies, glucose tolerance disease, post-infectious diarrhea), in- nomic circumstance or ignorance of test, IVP, bone marrow, peripheral creased metabolism (chronic infec- proper feeding and handling of infants smear and other tests to search for intions, malignancy), or poor cellular and children.7 Inadequate intake fection or neoplasms.6 7 Note that utilization (renal, cardiac or pulmo- (usually due to maternal neglect) ac- hypothyroidism, renal disease, inflamnary disease). A "therapeutic trial" counts for 50-90% of cases of failure matory bowel disease and celiac disease are frequently undetectable cliniTABLE 1 cally except for poor growth.1 Causes of Failure to Thrive 3. Inadequate intake and child fails Malnutrition Emotional deprivation Economic deprivation Ignorance of proper feeding techniques ENT disorder Malabsorption (celiac disease, cystic fibrosis) Genetic Conditions Familial short stature Constitutional delay in growth Trisomies Gonadal dysgenesis Others Endocrine disorders Hypothyroidism Panhypopituitarism Isolated growth hormone deficiency Cushing's syndrome (usually iatrogenic) Precocious puberty Others Chronic Systemic Disease Malignancies Chronic infections Collagen diseases Cardiac (congenital heart defects) 1570
Pulmonary (cystic fibrosis, asthma) Gastrointestinal (liver disease, inflammatory bowel disease) Renal Hematological (anemias) Metabolic (glycogen storage disease, maple syrup urine disease, cystinosis) Skeletal disorders Chondrodystrophies Rickets Mucopolysaccharidoses Osteogenesis imperfecta Renal osteodystrophy Central Nervous System Disorders Mental retardation Anomalies Tumors Hematomas
Intrauterine Growth Retardation Infection Placental insufficiency
Medications Methylphenidate Steroids
to gain. It is useful to divide this group on the basis of feeding behavior. Poor chewing or swallowing suggests a neurological, neuromuscular or ENT disorder (eg. cleft palate, nasal obstruction). Tiring after only a small amount is eaten suggests severely debilitating conditions such as congenital cardiac defects, chronic infections and
hypothyroidism. Chronic rumination or vomiting suggests GI anomalies, metabolic diseases and CNS conditions including any cause of mental retardation.5 B. The child with height reduced proportionately to or more than weight, and normal or slightly increased head circumference. In general, these children suffer from a skeletal, endocrine or genetic abnormality.6 An X-ray to determine bone age is helpful at this point.5 To do this, a PA projection of the left hand and wrist is compared to the standard presented by Greulich and Pyle.' 1. Normal bone age. CAN. FAM. PHYSICIAN Vol. 26: NOVEMBER 1980
All females in this group should such as hypothyroidism, growth horhave a buccal smear or chromosome mone deficiency and iatrogenic Cushanalysis to rule out Turner's syn- ing's syndrome.5 Therefore, lab work drome, since it can present in the ab- should include serum thyroxine, TSH sence of any detectable abnormality and pituitary function tests. A wide range of metabolic diseases except short stature.' Down's syndrome must also be ruled out. In the (hypophosphatemic rickets, hypophosabsence of the above conditions, the phatasia, mucopolysaccharidoses, glypatient likely has familial short stature. cogen storage diseases, renal tuberal In this case, there is usually a family acidosis, organic acidemias and history of short stature and a normal acidurias) and chronic diseases onset and progression of puberty can (chronic infections, malignancies, hebe expected5 (as opposed to constitu- patic, pulmonary and adrenal diseases) tional delay of growth). The ultimate also present in this group.5 Further inprognosis for the patient is a short vestigation would be influenced by history, physical and initial lab work, adult height. and would include such things as 2. Advanced bone age. This is most likely due to sexual serum calcium, phosphorus, alkaline precocity. This is accompanied by phosphatase, urinary amino acids and signs of androgen excess (eg. facial, liver enzymes. If the above investigaaxillary and pubic hair, penile or cli- tions are normal, the most likely diagtoral enlargement) or estrogen excess nosis is constitutional delay of growth. (breast enlargement, galactorrhea, There is usually a family history of delayed growth and puberty and the paetc. ).5 3. Retarded bone age. tient can be expected to reach a normal This group includes children with adult height by the end of his teens.9 endocrine causes of failure to thrive, No medical therapy is required.' Fig. 1. Outline of the investigative approach to failure to thrive.
An estimation of prognosis for fur-
nutritional
adequately
deprivation
Thorough history and physical, CBC, urinalysis, SMA-6 and stools
chronic disease
or
or neuromuscular
B. Weight percentile-.. Do bone age equal to height percentile C. Head circumference
IL
a.
CNS deficits aind chromosomal abnormalities
_
.
1.
ENT, neurological,
Poor swallowing
3. Inadequate intake
. A. Weight percentile less than height percentile -
Investigate appropriately
Malabsorption
2. Adequate intake but fails to gain I
LNormal headcircumference
Prognosis
. Emotional and/or
1. Child gains
Observational hospitalization (proper diet and lots of TLC)
Height and/or weight less than 3rd percentile, or mnarked deceleration in growth
C. The child with reduced head circumference, as well as reduced height and weight. Infants in this group usually suffer from a CNS disorder secondary to prenatal infection (rubella, cytomegalovirus, toxoplasmosis, etc.), placental insufficiency, perinatal difficulty (IRDS, hypoxia, etc.) or occasionally a chromosomal abnormality. Occasionally malnutrition may be so severe and long lasting as to result in a reduced head circumference.6 Although children with microcephaly may have normal intelligence, there is a strong statistical correlation between the degree of microcephaly and mental retardation.'0 These cases can be investigated further with a neurological exam, developmental assessment, transillumination of the skull, brain scan, etc.2 but in general there is little that can be done medically for these pathetic children.
Normal
Eats small
Cardiac disease,
amounts
hypothyroidism, other debilitating conditions
Rumination orvomiting
.Gl anomolies, metabolic, CNS including MR
iiRule out Down's
and Turner's Familial short stature 2. Advanced ---Sexual precocity
L3. Retarded iInvestigate for endocrine, metabolic and other chronic diseases -Constitutional delay in growth 1980 vol. 26: NOVEMBER 1980 CAN. FAM. PHYSICIAN Vol.
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ther growth can be based on diagnosis, onset and duration of disease, bone age, previous growth records and family height. The earlier the onset and the greater duration of the growth inhibiting factor, the worse the prognosis. A retarded bone age has a much better prognosis than an advanced bone age. 7 If the epiphyses are fusing, growth and height will cease within one to two years. Premature babies, in general, tend to catch up by three years of age, but small for dates infants have a much poorer prognosis and may never catch up.3
Conclusion The most common cause of failure to thrive (inadequate intake due to maternal neglect) can be diagnosed with a few basic lab tests and a short hospitalization. Using the approach outlined, other causes can also be diagnosed with a minimum expenditure of time and money. We hope this approach to failure to thrive will prove useful to busy family physicians in their management of this most interesting and prevalent problem.
References 1. McArthur RG et al: An approach to solving problems of growth retardation in the child and teenager. Can Med Assoc J 1977; 116:1012-1017. 2. Vaughan VC, McKay JR, Nelson WE: Textbook of Pediatrics, ed 10. Philadelphia, WB Saunders Company, 1975, pp 38, 1653-1654. 3. Heald FP et al: Effects of disease on physical growth. Postgrad Med, December 1977; 62:57-111. 4. Hoekelman RA et al: Principles of Pediatrics-Health Care of the Young. New York, McGraw Hill Incorporated, 1978, pp 1842-1845. 5. McMillan JA et al: The Whole Pediatric Catalog. Philadelphia, WB Saunders Company, 1977, pp 86-93. 6. Failure to thrive: A case study in comprehensive care. JFam Pract 1976; 3:659664. 7. Ziai M et al: Pediatrics, ed 2. Boston, Little, Brown and 'Company, 1975, pp 778-782. 8. Greulich WW, Pyle SI: A Radiographic Standard of Reference for the Growing Hand and Wrist. Cleveland, The Press of Case Western Reserve University, 1977. 9. Savage DC: The problem of retarded growth. Practitioner 1977; 218:513-520. 10. Hecht F, Kelly JV: Little heads-lnheritance and early detection, Part I. J Pediatr 1979; 95:731-732. 1572
WIurud lSketoprofen Bridges the gap between efficacy and tolerance THERAPEUTIC CLASSIFICATION: Anti-
inflammatory agent with analgesic properties. INDICATIONS: Treatment of rheumatoid arthritis, ankylosing spondylitis and osteoarthritis. CONTRAINDICATIONS: Active peptic ulcers or active inflammatory diseases of the gastrointestinal tract; suppositories should not be used in patients with any inflammatory lesions of rectum or anus, or a recent history of rectal or anal bleeding. Hypersensitivity to the drug. Because of the existence of cross sensitivity, Orudis should not be given to patients in whom acetylsalicylic acid and other non-steroidal antiinflammatory drugs induce symptoms of asthma, rhinitis or urticaria. WARNINGS: In pregnancy - Safety in pregnant or nursing women has not been determined and therefore use is not recommended. Pregnant rats who received ketoprofen 6 and 9 mg/kg/day p.o. from day 15 of gestation, showed dystocia and increased pup mortality. In children -The conditions for safe and effective use in children under 12 years of age have not been established and the drug is therefore not recommended in this age group. PRECAUTIONS: Use with caution in patients with a history of gastrointestinal inflammatory disorders or ulceration. Both capsules and suppositories carn cause upper gastrointestinal toxicity, including hemorrhage. Suppositories should be given with caution to patients with any rectal or anal pathology. The drug should be given under close medical supervision in patients with impaired liver or kidney functions. Orudis may mask signs of infectious diseases. This should be kept in mind so that any delay in diagnosing and treating infection may be avoided. Use in patients taking oral anticoagulants: Orudis has been shown to depress platelet aggregation in animals. However, in twenty patients undergoing therapy with coumarin, Orudis failed to demonstrate potentiation of anticoagulant effect. Nevertheless, caution is recommended when Orudis is given concomitantly with anticoagulants. The presence of Orudis and its metabolites in urine has been shown to interfere with certain tests which are used to detect albumin, bile salts, 1 7-ketosteroids or 1 7-hydroxycorticosteroids in urine and which rely upon acid precipitation as an end point or upon color reactions of carbonyl groups. No interference was seen in the tests for proteinuria using Albustix, Hema-Combistix or Labstix Reagent Strips. ADVERSE REACTIONS: Gastrointestinal: they were the most frequently observed and were seen in approximately 22% of patients. Ulceration and gastrointestinal bleeding have been noted in a few patients (approximately 0.8%). Other adverse reactions in order of decreasing frequency were: gastrointestinal pain, nausea, constipation, vomiting, dyspepsia and flatulence, diarrhea, anorexia and bad taste in
mouth. Rectal administration was associated with a lower incidence of upper gastrointestinal reactions (12%) with the exception of ulceration, the incidence of which was the same. However anorectal reactions presenting as local pain, burning, pruritus, tenesmus and rare instances of rectal bleeding occurred in 16.5% of subjects. 5% of patients discontinued rectal therapy because of these local reactions. Central Nervous System: headache, fatigue, dizziness, tension, anxiety, depression and drowsiness. Skin: rashes, pruritus, flushing, excessive perspiration and loss of hair. Allergic: urticaria, angioedema and asthma. Cardiovascular: mild peripheral edema, palpitation and bruising. Auditory system: tinnitus. Mouth: ulcers, sore tongue, inflammation of the mouth and gums. Laboratory Tests: Abnormal alkaline phosphatase, lactic dehydrogenase, glutamic oxaloacetic transaminase and blood urea nitrogen values were found in some patients receiving Orudis therapy. The abnormalities did not lead to discontinuation of treatment and, in some cases, returned to normal while the drug was continued. There have been sporadic reports of decreased hematocrit and hemoglobin values without progressive deterioration on prolonged administration of the drug. SYMPTOMS AND TREATMENT OF OVERDOSAGE: Symptoms: At this time, no overdosage has been reported. Treatment: Administer gastric lavage or an emetic and treat symptomatically: compensate for dehydration, monitor urinary excretion and correct acidosis if present. DOSAGE AND ADMINISTRATION: Adults: Oral: The usual dosage is 150 to 200 mg per day in 3 or 4 divided doses. Rectal: Orudis suppositories offer an alternative route of administration for those patients who prefer it. Administer one suppository morning and evening or one suppository at bedtime supplemented as needed by divided oral doses. The total daily dose of Orudis (capsules and suppositories) should not exceed 200 mg. When the patient's response warrants it, the dose may be decreased to the minimum effective level. In severe cases, during a flare-up of rheumatic activity or if a satisfactory response cannot be obtained with the lower dose, a daily dosage in excess of 200 mg may be used. However, a dose of 300 mg per day should not be exceeded. Children: Orudis is not indicated in children under 12 years of age because clinical experience in this group of patients is insufficient. Availability: Capsules of 50 mg, bottles of 100 and 500. Suppositories of 100 mg, boxes of 30. Store below 300C. Product information as of Nov. 11, 1979. Product
Monograph available on request.
RHONE-POULENC PHARMA Inc. 8580 Esplanade, Montreal S authorized user
CAN. FAM. PHYSICIAN Vol. 26: NOVEMBER 1980
