Pediatric Malnutrition: Under- and Over-weight in Children Daniel Jackson, MD Daniel Jackson, MD University of Utah School of Medicine University of Utah School of Medicine 2012 2012
Undernutrition: Global and Local Famine •Political Instability •Distribution of Resources •Social Chaos •Survival/Recovery
Nutrient Deficiency Maternal-Child Dyad •Maternal Nutrition/Health •Intrauterine Onset •Nursing insufficiency •Weaning/transition
Malabsorption •Environmental Factors •Infection: parasitosis •Malabsorption � reduced intake •Inflammation � increased energy needs
Kwashiorkor Displaced from nursing Low protein alternatives Endemic Infection GI protein loss Hypoalbuminemia � Edema
Marasmus Protein-Calorie Undernutrition Fat and Muscle depletion Preserved plasma proteins Preserved homeostasis
Failure to Thrive: Our world Genetics Prenatal environment Behavioral factors Psychosocial context Disease factors
To Thrive � Homeostasis Homeostasis � � Full physiologic function Full physiologic function � � Weight gain Weight gain � � Linear growth Linear growth � � Cranial growth Cranial growth � � Neurodevelopment Neurodevelopment � � Social integration Social integration �
Navigating The Growth Curve � Expectations Expectations � � Deviations Deviations � � Recovery Recovery � � Faltering Faltering � � Acute wasting Acute wasting � � Chronic stunting Chronic stunting � � Cranial stasis Cranial stasis �
CDC Growth Curves: 0-36 months
CDC Growth Curves: 2-20 years
Body Mass Index: kg/m 2
Body Mass Index [BMI] : 2 years to 20 years BMI = weight (kg) / height 2 (m 2 ) Extremely Obese: BMI >99 th %ile 95 Obese: BMI 95th to <99 th %ile 90 85 75 Overweight: BMI 85 th to <95 th %ile Overweight: 50 25 10 5 Centers for Disease Control and Prevention
Determination of % weight for height age: Actual Wt: 7 kg Expected Wt: 8.4 kg 7/8.4 = 0.83 or 83%
Hazards Around the Curve � Inadequate nutrient intake Inadequate nutrient intake � � Maldigestion Maldigestion � � Malabsorption Malabsorption � � Gut/Renal losses Gut/Renal losses � � Metabolic demands Metabolic demands � � Cardiopulmonary disease Cardiopulmonary disease � � Endocrinopathy Endocrinopathy � � Neuropathology Neuropathology � � Psychosociopathology Psychosociopathology �
Genetic/Congenital � Dysmorphic/chromosomal syndromes Dysmorphic/chromosomal syndromes � � Down Down’ ’s, Turner s, Turner’ ’s, Noonan s, Noonan’ ’s, Prader s, Prader- -Willi Willi � � Mutations Mutations � � Parental/sibling growth pattern Parental/sibling growth pattern � � Constitutional delay Constitutional delay � � Familial short stature Familial short stature � � Intrauterine growth retardation Intrauterine growth retardation �
Patterns of Failure to Thrive � Nutritional Nutritional � � Weight < Length < Head Weight < Length < Head � � Endocrine Endocrine � � Length < Weight < Head Length < Weight < Head � � Neurologic Neurologic � � Head < Weight < Length Head < Weight < Length �
Nutritional Pattern
Nutritional Pattern: DDx � Inadequate Net Intake Inadequate Net Intake � � Deprivation Deprivation � � Aversion, Dysphagia Aversion, Dysphagia � � Vomiting/Reflux Vomiting/Reflux � � Maldigestion/Malabsorption Maldigestion/Malabsorption � � Pancreatic Insufficiency: Cystic Fibrosis, Shwachman Pancreatic Insufficiency: Cystic Fibrosis, Shwachman � � Mucosal disease: Giardia/Cryptosporidia; viral enteritis; Celiac Mucosal disease: Giardia/Cryptosporidia; viral enteritis; Celiac � disease disease � Increased Metabolic Requirements Increased Metabolic Requirements � � Inflammation Inflammation � � Cardiopulmonary disease Cardiopulmonary disease �
Endocrine Pattern
Short Stature: Patterns Constitutional vs. Familial GH deficiency
Endocrine Pattern: DDx � Hypothyroidism Hypothyroidism � � Low Thyroxine (Free T4), High TSH Low Thyroxine (Free T4), High TSH � � Growth Hormone deficiency Growth Hormone deficiency � � Low Insulin like growth factor (IGF Low Insulin like growth factor (IGF- -1) 1) � � Unreliable in undernutrition states Unreliable in undernutrition states � � Low IGF Binding Protein 3 (IGFBP3) Low IGF Binding Protein 3 (IGFBP3) � � Hypopituitarism Hypopituitarism � � Low cortisol, TSH, glucose, gonadotropins Low cortisol, TSH, glucose, gonadotropins �
Neurogenic Pattern macrocephalic microcephalic
Neurogenic Pattern: DDx � Microcephalic Microcephalic � � Infarction Infarction � � CMV viral infection CMV viral infection � � Embryogenic defect: Embryogenic defect: � � neuronal migration neuronal migration � � Rett syndrome Rett syndrome � � Macrocephalic Macrocephalic � � Hydrocephalus Hydrocephalus � � Tumor Tumor � � Brainstem: Diencephalic syndrome Brainstem: Diencephalic syndrome � � Metabolic storage disease Metabolic storage disease � � Autism Autism �
Rett Syndrome Autism
Diencephalic Syndrome
FTT: Definition � Static Criteria: Static Criteria: � th %ile Weight for Height < 5 th � Weight for Height < 5 %ile � � Weight < 85% median weight for height Weight < 85% median weight for height � Triceps skinfold thickness < 5 mm or < 5 th th %ile � Triceps skinfold thickness < 5 mm or < 5 %ile � � Dynamic Criteria: Dynamic Criteria: � � Subnormal growth velocity: Subnormal growth velocity: � � <20 g/d @ 0 <20 g/d @ 0- -3 months 3 months � � <15 g/d @ 3 <15 g/d @ 3- -6 months 6 months � � Drop of 2 major centiles Drop of 2 major centiles �
Diagnostic Approach � Prenatal/Perinatal medical history Prenatal/Perinatal medical history � � History of medical/surgical illness History of medical/surgical illness � � Diet history Diet history � � Weaning, Food introduction Weaning, Food introduction � � Meal Structure: intervals, schedule Meal Structure: intervals, schedule � � Family History Family History � � Physical Examination Physical Examination � � Strategic laboratories and Radiology Strategic laboratories and Radiology �
Diagnostic Evaluation � History: History: � � Maternal Health Maternal Health � � GA, BW, Perinatal, Infancy, Development, Medical and Surgical GA, BW, Perinatal, Infancy, Development, Medical and Surgical � illness, interventions illness, interventions � Link events to growth history: map on curve Link events to growth history: map on curve � � Feeding history Feeding history � � Nursing/weaning Nursing/weaning � � Sequence of foods: introduction of solids Sequence of foods: introduction of solids � � Frequency of feeding Frequency of feeding � � Coercive feeding Coercive feeding � � Parental/infant feeding transactions/communication Parental/infant feeding transactions/communication � � Psychosocial Problems Psychosocial Problems �
Diagnostic Evaluation � Physical Examination: Physical Examination: � � Measurements Measurements � � Hygiene Hygiene � � Dysmorphisms: craniofacial, skeletal,etc. Dysmorphisms: craniofacial, skeletal,etc. � � Epithelial integrity: skin, hair, nails, eyes, mucosa Epithelial integrity: skin, hair, nails, eyes, mucosa � � Edema Edema � � Micronutrient deficiency Micronutrient deficiency � � Body composition: fat and muscle stores Body composition: fat and muscle stores � � Cardiorespiratory status Cardiorespiratory status � � Neurodevelopmental status Neurodevelopmental status � � Dysphagia Dysphagia � � Functional status: tone, responses, strength Functional status: tone, responses, strength � � Child Child- -Parent and Child Parent and Child- -Examiner interactions Examiner interactions �
Digital Clubbing
Digital Clubbing Cystic Fibrosis Celiac Sprue Cyanotic Heart Disease Cirrhosis Crohn Disease COPD Candidiasis Mucocutaneous Congenital
Acrodermatitis enteropathica Zinc deficiency
Noonan Turner
Fetal Alcohol
Williams
Acute vs Chronic � Acute Undernutrition Acute Undernutrition-- -- “ “wasting wasting” ”: : � � Low weight for height or low BMI Low weight for height or low BMI � � “ “wasting wasting” ” of fat and muscle mass of fat and muscle mass � � Prelude to stunting Prelude to stunting � � Constitutional leanness Constitutional leanness � � Chronic Undernutrition Chronic Undernutrition– – “ “stunting stunting” ”: : � � Low height for age Low height for age � � Normalized weight for height and BMI Normalized weight for height and BMI � � Consider constitutional growth delay Consider constitutional growth delay � � Consider Endocrinopathy: hypothyroidism, hypopituitarism Consider Endocrinopathy: hypothyroidism, hypopituitarism �
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