1000-2000 5 ьшò

(2)[B]

Aperiod of addressing nutritional causes is preferable prior to extensive labs and other workup.

Initial Tests (lab, imaging)

Labs should be ordered based on history and physical exam findings and the age of the patient.

Tests often considered in initial evaluation:

–CBC, ESR

–Electrolytes, BUN/creatinine, liver function tests

–Urinalysis and urine culture

–Lead level

Other tests as dictated by the history and exam:

–TSH, amylase/lipase, serum zinc level, iron studies, karyotype, genetic testing, sweat chloride test, stool for ova and parasite or fat/reducing substances, guaiac, α1-antitrypsin and elastase, radioallergosorbent test for IgE food allergies, tissue transglutaminase and total IgA(celiac sprue), p- ANCAand anti–Saccharomyces cerevisiae antibodies (for inflammatory bowel disease [IBD]), TB test, HIV, ELISA, hepatitis Aand B, other infections

Follow-Up Tests & Special Considerations

Prospective 3-day food diary for accurate record of caloric intake should be obtained.

Home visit by a clinician to observe infant feeding, interaction of caretakers, and home environment (3)[B],(4)

Observe breastfeeding and/or formula preparation to ensure adequacy and offer instruction.

Additional indicated evaluations may be performed by dietitians; occupational, physical, and speech therapists; social workers; developmental specialists; psychiatrists; psychologists; visiting nurses; lactation consultants; and/or child protection services.

Can consider

–Skeletal survey if suspicion of physical abuse

–Bone age if possible endocrine disorder

–Swallowing studies, small bowel follow-through if possible oromotor dysfunction, GERD, structural abnormalities

–Brain imaging if microcephalic and/or neurologic findings on examination

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– Echocardiogram if murmur auscultated

TREATMENT

GENERALMEASURES

Treat underlying conditions.

Caregiver and infant interaction should be evaluated in infants and children with FTT.

Age-appropriate nutritional counseling should be provided (1)[C].

– The goal is to improve nutrition to allow catch-up growth (weight gain 2 to 3 times > average for age).

Calculate energy needs based on recommended energy intake for age and then increase by 50%.

–Recommended energy intake (use expected median weight for age, not actual weight)

0 to 1 month: 120 kcal/kg/day

1 to 2 months: 115 kcal/kg/day

2 to 3 months: 105 kcal/kg/day

3 to 6 months: 95 kcal/kg/day

6 months to 3 years: 90 kcal/kg/day (2)[C]

Alternatively, may calculate caloric requirements for infants to achieve catchup growth

–kcal/kg/day required = RDAfor age (kcal/kg) × ideal weight for height/actual weight, where ideal weight for height is the median weight for

the patient’s height

Try various strategies to increase caloric intake, such as the following:

–Optimize breastfeeding support; consider supplementation.

–Higher calorie formulas

–Addition of rice cereal or fats to current foods

–Limit intake of milk to 24 to 32 oz/day.

–Avoid juice and soda.

–Vitamin and/or nutritional supplements

–Assist with social and family problems (WIC, food stamps, and other

transitional assistance).

Rapid high-calorie intake can cause diarrhea, malabsorption, hypokalemia, and hypophosphatemia. Therefore, increasing formulas >24 kcal/oz is not recommended.

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The target energy intake should be slowly increased to goal over 5 to 7 days.

Catch-up growth should be seen in 2 to 7 days.

Accelerated growth should be continued for 4 to 9 months to restore weight and height.

MEDICATION

Use only for identified underlying conditions.

ISSUES FOR REFERRAL

Refer as indicated for underlying conditions.

Multidisciplinary care is beneficial (1)[A]. Specialized multidisciplinary clinics may be of benefit for children with complicated situations, failure to respond to initial treatment, or when the PCPdoes not have access to specialized services such as nutrition, psychology, PT/OT, and speech therapy.

ADDITIONALTHERAPIES

In severe cases, nasogastric tube feedings or gastrostomy may be considered.

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Most cases of FTT can be managed as outpatients. Hospitalization should be considered if (1)[C]:

–Outpatient management fails.

–There is evidence of severe dehydration or malnutrition.

–There are signs of abuse or neglect.

–There are concerns that the psychosocial situation presents harm to child.

–During catch-up growth, some children will develop nutritional recovery syndrome:

Symptoms include sweating, increased body temperature, hepatomegaly (increased glycogen deposits), widening of cranial sutures (brain growth

>bone growth), increased periods of sleep, fidgetiness, and mild hyperactivity.

–There may also be an initial period of malabsorption with resultant diarrhea.

Catch-up growth should be seen in 2 to 7 days. If this is not seen, reevaluation of causes is needed.

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ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

If specific disease is identified, follow up as indicated.

Close, long-term follow-up with frequent visits is important to create and maintain a healthy, supportive environment (3)[B],(4).

Children with history of FTT are at increased risk of recurrent FTT, and longterm sequelae and growth should be monitored closely (1,2),(3)[B].

If the family fails to comply, child protection authorities must be notified.

DIET

Nutritional requirements for a “normal” child: Infant

–120 kcal/kg/day, decreased to 95 kcal/kg/day at 6 months; if breastfed, ensure appropriate frequency and duration of feeding.

–Between 6 and 12 months, continue breast milk and/or formula, but pureed foods should be consumed several times a day during this period.

Toddler

–Three meals plus two nutritional snacks, 16 to 32 oz of milk/day; avoid juice and soda and feed in a social environment.

–Do not restrict fat and cholesterol in children <2 years.

Rate of weight gain expected for age:

–0 to 3 months: 26 to 31 g/day

–3 to 6 months: 17 to 18 g/day

–6 to 9 months: 12 to 13 g/day

–9 to 12 months: 9 g/day

–1 to 3 years: 7 to 9 g/day

PATIENT EDUCATION

Counsel parents regarding the need to avoid “food battles,” which worsen the problem.

Educate parents regarding infant social and physiologic cues, formula/food preparation, proper feeding techniques, and importance of relaxed and social mealtimes.

When environmental deprivation is identified, educating in a nonpunitive way is essential.

“Failure to thrive: What this means for your child,” available from AAFPat:

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www.aafp.org/afp/2011/0401/p837.html

WIC provides grants to states for supplemental foods, health care referrals, and nutrition education for low-income pregnant, breastfeeding, and nonbreastfeeding postpartum women and to infants and children up to age 5 years at nutritional risk: www.fns.usda.gov/wic/.

PROGNOSIS

Many children with FTT show adequate improvement in dietary intake with intervention.

Some studies looking at children with FTT have demonstrated an association with later problems with cognitive development, behavioral issues, and growth, but there is no consensus on these long-term outcomes or their clinical significance (1).

Children with FTT are at increased risk for future undernutrition, overnutrition, and eating disorders.

REFERENCES

1.Cole SZ, Lanham JS. Failure to thrive: an update. Am Fam Physician. 2011;83(7):829–834.

2.Krugman SD, Dubowitz H. Failure to thrive. Am Fam Physician. 2003;68(5):879–884.

3.Black MM, Dubowitz H, Krishnakumar A, et al. Early intervention and recovery among children with failure to thrive: follow-up at age 8. Pediatrics. 2007;120(1):59–69.

4.Shields B, Wacogne I, Wright CM. Weight faltering and failure to thrive in infancy and early childhood. BMJ. 2012;345:e5931.

ADDITIONALREADING

Atalay A, McCord M. Characteristics of failure to thrive in a referral population: implications for treatment. Clin Pediatr (Phila). 2012;51(3):219– 225.

Jaffe AC. Failure to thrive: current clinical concepts. Pediatr Rev. 2011;32(3):100–107.

Kerzner B, Milano K, MacLean WC Jr, et al. Apractical approach to classifying and managing feeding difficulties. Pediatrics. 2015;135(2):344– 353.

Larson-Nath C, Biank VF. Clinical review of failure to thrive in pediatric

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patients. Pediatr Ann. 2016;45(2):e46–e49.

CODES

ICD10

R62.51 Failure to thrive (child)

P92.6 Failure to thrive in newborn

CLINICALPEARLS

FTT is a sign of inadequate nutrition. It is rarely due to a medical condition.

Underlying medical and/or social issues are generally suggested by history and physical exam, and extensive laboratory or imaging tests are rarely needed.

Amultidisciplinary team approach to diagnosis and treatment is critical to help children with FTT and their families.

Prompt diagnosis and intervention is important to decrease the risk of adverse effects.

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FEMALE ATHLETE TRIAD

Kyle Meyer, DO Rahul Kapur, MD

BASICS

Syndrome of three interrelated clinical entities: low energy availability (EA) (with or without disordered eating [DE]), menstrual dysfunction (MD), and low bone mineral density (BMD) (1)

DESCRIPTION

Female athlete triad was first described in 1992: Patients may meet criteria for only one or two parts of the triad.

Prevention and early intervention are essential to prevent progression to serious clinical end points of eating disorders, amenorrhea, and osteoporosis. 2014 Female Athlete Triad Coalition Consensus Statement and the 2007 American College of Sports Medicine (ACSM) Position Stand suggest (1):

–Each component of the triad represents a spectrum ranging from health to dysfunction.

–EAis fundamental to the propagation of the triad.

–Full recovery is not possible without correction of low EA.

The International Olympic Committee’s updated position statement from 2014 now considers Relative Energy Deficiency in Sport (RED-S) to be a more accurate representation of the psychological and physiologic stresses placed on the athlete’s body.

Metabolic rate, menstrual function, bone health, immunity, protein synthesis, cardiovascular and psychological health are all effected (2).

RED-S also takes into account the effects of relative energy deficiency on male athletes, who are often affected in weight-sensitive sports (gymnastics, wrestling, cycling, etc.) (2).

The changes in physiology should be viewed as a spectrum, with normal EA, BMD, and regular menses at one extreme and clinical eating disorders, osteoporosis, and amenorrhea at the other (2).

EA

–Dietary energy intake minus exercise energy expenditure; the core element of the triad

–Represents the amount of dietary energy remaining for bodily functions after correcting for exercise training

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–EA(kcal/kg FFM/day) = [EI (kcal/day) − EEE (kcal/day)] where EEE is effective energy expenditure and FFM is fat free mass

–Low EAresults in reduced capacity for cellular maintenance, thermoregulation, and growth.

–Low EAserves a causal role in the induction of exercise-associated menstrual disturbances.

–Low EAoccurs either intentionally or inadvertently. Examples include increasing training disproportionately to energy intake; DE; and reducing energy intake by restricting, fasting, binging, and purging or use of diet pills, laxatives, diuretics, or enemas. Not all athletes meet diagnostic criteria from Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) for eating disorders.

MD

–Low EAalters the hypothalamic-pituitary axis, resulting in decreased estrogen levels.

–MD ranges from eumenorrhea to amenorrhea.

–MD includes athletes who have low estrogen levels but still experience menstruation.

–Energy deficit results in MD at ~30 kcal/kg lean body mass per day.

–MD includes luteal suppression (shortened luteal phase, prolonged follicular phase, and decreased estradiol level), anovulation, oligomenorrhea (menstrual cycle >35 days), and primary and secondary hypothalamic amenorrhea.

–Primary amenorrhea (no menarche by age 15 years), although less common, can occur in young athletes. Secondary amenorrhea is defined as the absence of menstrual cycles for >3 months after menarche established.

–Although hypothalamic suppression is the most common cause of

secondary amenorrhea in these athletes, other causes must be ruled out. BMD

–Ranges from optimal bone health to osteoporosis

–Peak BMD occurs at 19 years in females and 20.5 years in males.

–Bone health encompasses bone strength as well as bone quality. The current practice standard (dual energy x-ray absorptiometry [DEXA]) measures bone density, not bone quality. This research may help providers better understand why two athletes with the same BMD may have very different bone fracture histories (3).

ACSM Position Stand recommends using the International Society of Clinical Densitometry (ISCD) guidelines for BMD Z-scores <−2.0. Because most athletes have a higher BMD than nonathletes, ACSM

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recommends further workup for any athlete with a Z-score <−1, even in the absence of fracture.

–Endothelial dysfunction

Emerging evidence suggests that the female athlete triad is associated with endothelial dysfunction. Reduced levels of estrogen alter vasodilation. Athletic amenorrhea is associated with reduced brachial artery flow-mediated dilation, which has a 95% positive predictive value for coronary endothelial dysfunction. Consequences include decreased blood flow to muscles during exercise and accelerated atherosclerosis. In the future, this clinical syndrome may be considered a tetrad (4).

EPIDEMIOLOGY

Prevalence

Overall prevalence: 0–16% of female athletes (5). Prevalence of two criteria varies: MD + BMD 0–8% (n = 460), MD + LE 18% (n = 80), and BMD + LE 4% (n = 80) (3)

DE higher than general population (3)

MD: Prevalence of secondary amenorrhea is as high as 60% in female athletes compared to 2–5% in the general population (3).

Bone health: Using the World Health Organization (WHO) criteria for low BMD, prevalence of osteopenia (T-score between −1 and −2) ranges from 0% to 40% in female athletes, as compared to ~12% in the general population (3).

ETIOLOGYAND PATHOPHYSIOLOGY

In functional hypothalamic amenorrhea, low EAdisrupts the hypothalamic- pituitary-ovarian axis, decreasing pulsatile gonadotropin-releasing hormone (GnRH) release (5).

Low GnRH levels decrease luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels, decreasing estrogen production with resultant MD.

Estrogen deficiency negatively affects bone density. Achronic state of malnutrition reduces the rate of bone formation and increases the rate of bone resorption. Changes in bone metabolism occur within 5 days of reductions in EA.

RISK FACTORS

History of menstrual irregularities and amenorrhea; history of stress fractures and recurrent or non-healing injuries; history of critical comments about eating or weight from parent or coach; history of depression; history of

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dieting; personality factors including perfectionism and/or obsessiveness, overtraining, and inappropriate coaching behaviors (1)

Lean physique, sports with an aesthetic component (ballet, figure skating, gymnastics, distance running, diving, and swimming), or sports with weight classifications (martial arts and wrestling). Frequent weigh-ins, consequences for weight gain, and win-at-all-cost attitude all increase risk (2).

Alack of family or social support; intense training hours; social isolation, or entering a new environment (boarding school or college); an athlete with comorbid psychological conditions (anxiety, depression, and/or obsessivecompulsive disorder)

GENERALPREVENTION

Education of athletes (middle school through college), coaches, trainers, parents, and physicians. Young athletes are extremely impressionable and may turn negative comments and unhealthy advice into maladaptive eating and exercising habits.

General screening during preparticipation exam (PPE) and annual physicals are endorsed by AAP, AAFP, ACSM, AAOSM, and AMSSM (6).

Female Athlete Triad Coalition has 11-question screening to use during PPE (1).

Screen athletes presenting with “red flag” conditions such as fractures, weight changes, fatigue, amenorrhea, bradycardia, orthostatic hypotension, syncope, arrhythmias, electrolyte abnormalities, or depression.

COMMONLYASSOCIATED CONDITIONS

Anorexia nervosa, bulimia nervosa, avoidant or restrictive food intake disorder, and other psychological disorders, including low self-esteem, depression, and anxiety (5)

Low BMD predisposes athletes to stress fractures and may not be fully reversible. This may lead to a higher rate of fractures after menopause.

DIAGNOSIS

The female athlete triad is a clinical diagnosis based primarily on patient history; screening for the female athlete triad at annual sports physicals or during routine exams and acute visits if there are concerns (1,5)[A] EDE-17 is the gold standard for eating disorder diagnosis.

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