North Carolina Pediatric Society 2010 Annual Meeting

NC Pediatric Society Annual Meeting 2010

July 29 to August 1, 2010

Hilton Myrtle Beach

So if you're new to the blog, let me begin with a disclaimer: this is my best attempt to capture the conference as it was coming at me. For complete content there is a flash drive full of magnificent slide shows with all the details from most of the talks. (For a more realistic experience read a little, then break for a dry turkey sandwich and an apple, then read some more, then pay way too much for a glass of cheap wine and talk to someone near you about what you've been up to since residency.) There may have been stuff I didn't hear, or I might have had to take a potty break at some point. One afternoon I was actually lecturing along with Kathleen Clarke-Pearson and Gerri Mattson on digital media and its impact on pediatrics, and I was unable to take photos or myself or take notes during my talk. That said, we'll be happy to re-enact the lecture at a grand rounds near you with the merest invitation.

After all that disclaiming, let me claim that as always I learned some super-useful pearls, and they're all here except for Christoph Diasio's fantastic talk on everything having to do with getting paid appropriately for vaccinating kids, which happened after dinner at a time when I chose not to bring my computer and camera back downstairs with me. You can email Christoph for a copy of his notes. If you skim the notes below you'll get the points that I found to be most practice-changing from each lecture, which may just show all y'all how little I actually know.

Finally, as tempting as it is to skip over the public health, political, and practice management stuff and just go to the not-killing-patients parts, it's the policy stuff that allows us to provide good care for children. Every year when I go to this meeting I am impressed by the number of amazingly talented people working on policy to make sure our patients get the best care programs in the country and we get paid to see them. If I bothered to type it here, it will probably affect what you do in your office. I'll make a plug here for advocacy: if the FMAP extension gets defeated and Medicaid reimbursement drops by half and you didn't call your Senator (Burr) in support of the legislation, well, you were warned.

Dr. Marian Earls opens her finally meeting as president.

As always we start by introducing ourselves, over 200 of us from all over the state. It makes lousy photos.

Dr. Laura Gerald

Dr. Charles Wilson

Good For Kids Award

• Health And Wellness Trust Fund
• Accepted by Charles Wilson, MD and the new Executive Director, Dr. Laura Gerald.

Update on Vision Screening in North Carolina

Talbot, MA Ed, Prevent Blindness NC

Anya Helfrich, MPA

Dr. Alex R. Kemper from Duke unable to be here today.

• New national Center for Children’s Vision and Eye Health from the Maternal and Child Health Bureau
• North Carolina chosen because we’ve had a task force since 1994 to accomplish early identification of vision problems in young children
• Medicaid covers vision screening under Early Periodic Screening, Diagnostic, and Treatment program
• New law requires standardized vision screening as part of the Kindergarten Health Assessment
• Failure on screen must be referred to an eye care professional for a vision exam
• PBNC arranges Donor Doctors to provide free exams and glasses
• VSP Sight for Students
• PBNC Donor Docs
• Healthy Eyes Eyeglass Program
• Download applications for these programs at www.preventbilndness.org/nc
• Duke project is funded by the CDC
• Led by Dr. Alex Kemper at Duke, a pediatric epidemiologist
• Aims are
• Quantify benefit of school-based vision screening
• Evaluate strategies for detecting and factos associated with developing amblyopia in the primary care setting
• Develop a Continuous Quality Improvement system for pediatricians which builds on the ABP Maintenance Of Certification requirements and supports school based screening.
• Now in the third year, hoping to distribute tools nationwide to help pediatricians
• Free module will be available later this year for performance improvement which will meet MOC requirements for the American Board of Pediatrics
• Call NCPB with any questions at 919-755-5044

Dr. Des Runyan, UNC

The Period of PURPLE Crying

• Goal is to reduce shaken baby syndrome by 50% over 5 years.
• Three dose program: booklet and DVD given at the hospital at birth, reinforced at the primary care physician’s office, then again in a media campaign
• Last year 64 children were shaken, over the goal of 50 for the year, although the increase is less than appears to be the case nationwide, attributed to economic stress
• Goal was to have 650 MD’s teaching the PURPLE crying system, now over 1000 actually involved, now at least one MD in every county in the state
• Designated person at the office hands out the reinforcement card to new parents, also review card with caregivers, hang posters in office, provide DVD’s, play the DVD for parents, and train staff about PURPLE crying.
• Radio spots are running in Raleigh/Durham, New Bern, and Fayetteville. Military families are at 5x risk for shaken baby
• Can check website www.purplecryingnc.info
• Can also fan Facebook page.

Beth Rowe-West, RN, BSN

NC Immunization Branch

Pediatric Vaccines

• There is no more state vaccine program
• Did get $3 million to help get through the school requirements this year, which is not enough funding
• Idea was to give funds to health departments to administer school vaccines, but departments were given a choice
• Goal was MMR, TDaP, and Polio, all we could afford for $3M. Could not afford varicella
• By September this supply will be completely used up.
• Problems with vaccination is both due to parental refusal and also to insurance companies not adequately covering vaccines, has contributed to pertussis outbreak in California.
• Vaccines For Children does cover children whose insurance policy does not cover vaccines or has a cap that limits vaccine coverage and has been exceeded. These children are called “UNDER-insured.” But if insurance covers even a dollar of the vaccine cost, pediatricians cannot use VFC vaccines for these children.
• NC Health Choice is not covering the full cost of Varicella vaccine. Dr. David Tayloe is working on this issue with the state government.
• NC may win a grant to make the NCIR system bi-directional to integrate with practice electronic medical records.
• Over 85% of providers in NC are now using the North Carolina Immunization Registry
• NC Immunization Branch is required to visit our offices every other year as a part of their grant
• If your practice is in danger of stopping giving vaccines altogether, please contact Dr. Graham Barden or Dr. Christoph Diasio of the Practice Management section of the NCPS. They may be able to help you figure out how to get paid enough to keep giving vaccines.
• You may charge an administration fee when giving VFC vaccines, but if parents state they cannot pay it then you are legally obligated to waive the fee

Deborah Caroll, PhD

Updates in Public Health

Deborah Carroll, PhD, Gerri Mattson, MD, FAAP from the Division of Public Health and Marcia Mandel, PhD, of the Raleigh CDSA

• Early intervention program serves children birth to age 3, governed under Individuals With Disabilities Education Act
• Anyone can refer to CDSA. Look at www.ncei.org

Marcia Mandel on Primary Provider Model

• Designed to emphasize service delivery by one person who can coach parents and other caretakers to help integrate developmental integration
• The idea is to make the interventions a part of daily life, not just a weekly event.
• Model includes a transdisciplinary team whose members coordinate care through regular meetings and cooperation
• Team leader (Primary Provider) is the team member whose services are most key to the child’s development.

Gerri Mattson, MD, MSPH, FAAP

Children and Youth Branch Update

• School nurses are the best link with the medical home
• School nurses are licensed RN’s, and 50% have national school nurse certification
• Our ratio of school nurses to students would ideally be 1:750, current average is 1:1257, better than it was five years ago.
• Over 80,000 episodes reported of health counseling last year across the state
• Health care treatments and procedures: over 30,000 events across the state last year including tube feeds, epipen use, line access, etc.
• 30,000 medications given daily last year, nearly 50,000 non-daily medications administered
• At this time 17% of students have documented chronic health conditions, up from 8% in 1999
• Minor changes in Kindergarten Health Assessment
  BMI categories to match CDC, Dentist information added, developmental tools streamlined.
• Parent sections to be translated to Spanish
• Newborn screening in NC identified 22 cases of Cystic Fibrosis, just added in April, 2009
• Look for a survey on newborn screening coming in the next couple of months.
• New system is launching to report newborn screen results, being debugged, should include CF results as well as all the other results.
• For children born since July 13th, the results have not been online, but may be fixed today.

Pediatric Academic Department Updates

• New docs at Wake Forest
• Julie Beyerly is taking over as Residency Director as Dr. Harvey Hamrick retires
• ECU applying to be a CF center, has a new pediatric surgeon
• Duke hiring a new pediatric heart surgeon, expanding NICU
• Levine Children’s Hospital working as are the other programs to comply with new residency work hour restrictions. Recruiting a sixth pediatric GI doctor, two new cardiologists, a new heart surgeon

AAP Update

. Francis Rushton, MD, FAAP, Chairman, District IV

• Child Health Informatics Center and the HITECH Act
• New center working on a model EMR
• Compiling data on pediatric EMR experiences
• Working on modifying the HITEC act to account for pediatric needs
• To qualify for reimbursement you need to have 20% Medicaid, and reimbursement goes up of Medicaid is over 30%
• Must have certified EMR, except that those criteria have not yet been released. Good bet that CCHIT 2011 standards will be among the criteria.
• You will need to meet meaningful use requirements, now 15 must-have criteria, then meet 5/10 optional criteria
• You will need to meet quality reporting requirements, most of which don’t apply to children. There are a few that do apply.
• Visit the AAP Member Center for more information
• Health Care Reform
• Access to covered services through appropriate payment rates and workforce improvements
• Benefits that are age appropriate and offered through a medical home
• Coverage for health care for all children in the United States
• We did get $8.3 billion to achieve parity between Medicaid and Medicare payments
• Bright Futures services are covered with no co-pay
• Medicaid medical home demonstration project money
• Now Medicaid will cover 32 million additional children, parents, and individuals
• Tax credits will help pediatric practices provide health insurance for their employees
• The AAP accomplished many of our goals for children’s health care
• AAP Strategic Plan
• PIllars include access, quality, and finance, all addressed by health care reform
• Focus on Early Brain and Child Development
• Special Health Care Needs/Foster Care a focus this year.

Jane Foy, MD addresses mental health priorities of AAP

• NCPS has worked with Medicaid to reimburse mental health services provided by primary care physicians.
• Policy statement published in July, 2009 in Pediatrics covering pediatricians’ competency to provide mental health care. AAP provides CME for this subject to bring pediatricians up to date. These competencies are specific to the pediatric setting and not the same as what a psychiatrist would need.
• Supplement to Pediatrics published June, 2010 to guide pediatricians in providing mental health services in the office setting
• There are some simple, easily incorporated techniques to help pediatricians cope with mental health problems they may identify among their patients.
• The mental health toolkit includes a practice readiness assessment, a set of algorithms for identifications and treatment of mental health problems, a symptom checking tool to go from symptoms to simple interventions

Theresa Flynn, MD spoke on the new Medicaid and NC Health Choice Preferred Drug List

• The new list includes some brand name products because the manufacturers are giving the government rebates that make them less expensive than generic equivalents
• Some medications will be automatically approved for certain ages (Accuneb under age 2 years, Prevacid under age 12)
• The new prior authorization forms are simplified and easy to use
• Some medications will be approved on the basis of how sick the child is, specifically for asthma
• QVAR remains the only approved inhaled corticosteroid over age 5 years
• There will be a six month period to change asthma medications to the preferred medication

John Rusher, MD, PhD

State Legislative Update

Our efforts this year were focused largely on containing the damage to pediatrics resulting from massive cuts to state budget

• The huge elephant is whether the FMAP re-allocation will be passed by the US Senate before January, 2011.
• Without FMAP we will be facing enormous cuts in provider reimbursement through Medicaid
• This year we were able to preserve
• Funding for inpatient mental health services
• Maintained Medicaid reimbursement rate for primary care providers (91.44% of Medicare rates)
• NC Health Choice
• Fitness testing in schools
• Child Nutrition Program Study
• Improved nutritional standards and activity standards in Early Childhood Education/Day cares
• Require provider certification for licensed day care facilities.
• Funds to pay for hearing aids up to age 21
• Banned corporal punishment in schools for children with disabilities
• Pharmacists lost their fight to give vaccines without a doctor’s orders to children under age 14 years.
• We lost
• Vaccines for Children save $3M to get most but not all school entry vaccines (cannot afford varicella)
• Please contact the NC Pediatric Society if you run into problems getting children needed vaccines, especially due to high-deductible or restrictive insurance policies. At this time we really have no idea how many children fall into that category.
• Specialty providers’ Medicaid fees were reduced, now around 88% of Medicare, which may threaten children’s access to pediatric specialists
• NC Pediatric Society is keeping an active hand in several relevant study groups and task forces while the legislature is not in session
• Our Executive Director, Steve Shore, is also our registered lobbyist, and he works closely on a daily basis with legislators, serving as their primary source on pediatric issues
• We also have two paid lobbyists in Raleigh who extend our reach and follow active issues as they are evolving
• Senator Bill Purcell, MD continues to work hard in support of pediatric issues in the Senate.
• Dr. Purcell stands to thank Steve Shore and John Rusher for their diligent work in the legislature on our behalf.
• $1 billion have been cut from state mental health and health funding since 2008.
• If we don’t get FMAP passed in the US Senate we will be faced with dire cuts to our services.
• Please contact Senator Burr’s office and ask him to reverse his opposition to FMAP funding extension
• Big money was already taken from the Health And Wellness Trust Fund
• Medicaid cuts ended up being $26 million dollars more than initially authorized.
• Olson Huff, MD stands to speak on FMAP extension. The Washing office tells us that FMAP will be debated on Monday, August 2nd. It is critical that we all call Senator Burr’s office Monday to support the FMAP legislation

Dr. David Tayloe takes a moment to thank everyone for their memories of his father, David Tayloe, Sr., one of the founding giants of the NC Pediatric society and of the practice of pediatrics in North Carolina, to whom this annual meeting was dedicated.

Bettina M Gyr, MD

Pediatric Orthopedic Surgery

Brenner’s Children’s Hospital

• If you think it’s fractured just send it to orthopedics and let them do the x-rays
• Start clubfoot casting at 3-4 weeks of age
• If your club foot patient has been in a cast longer then 3 months something is wrong
• Hip ultrasounds should be held until after 14 days of age, under that they’re always abnormal!
• Let the ultrasound be done at the orthop’s office, not at your hospital
• Children do get back pain, but if there is not an neurologic abnormality just get an x-ray, nothing more.
• Most common referrals are for bowlegs, knock knees, in toeing, and out toeing, flat feet
• Two year olds are bow-legged, four year olds are knock kneed naturally
• Under age three bow legs are ALWAYS normal, maximal at age 18 months
• Usually resolves by age 3 - 3.5 years
• Could be Blount, Rickett’s
• Blount’s is ASYMMETRIC bowing
• Bracing DOES NOT WORK based on evidence based medicine
• Surgery may be indicated based on severity
• Guided growth
• Simple outpatient procedure
• Must be treated before growth is complete
• Knock knees are normal between ages 3-5
• Refer if deformity is past school age or is asymmetric
• Get standing films
• In-toeing normal under age 6
• Femoral anteversion, tibial torsion both common
• Check prone rotational exam
• Just reassure before school age
• NO role for shoes or bracing, the problem is the femur!
• The only real treatment is femoral osteotomy, which is a major surgery
• Not treating rarely results in severe disease later
• Out-toeing is also normal, but look for ataxia or other neurologic disturbance
• No role fro bracing or special shoes
• Rotational osteotomy is the only repair
• Teens with pain may need therapy
• Baby feet come all shapes and sizes, often flat up to age 8 years
• No one needs an arch, you can even join the Army with flat feet
• HIGH arches are much more scary, suggest neurologic disease
• Pain, rigidity, tight achilles, and neurologic abnormalities are ABNORMAL
• Exam when standing on toes, which should create and arch
• NO point to orthotics or special shoes except soft inserts or shoes if painful
• Pain may be due to tarsal coalition, may be treated surgically as a last resort after all else fails
• Ortho knows these referrals are often driven by anxious parents

Chap McQueen, MD, FACS

Alamance ENT, Burlington, NC

Common ENT Referrals: the Top 3.5

• Ear infections: “He needs those long-lasting tubes.”
• Refer for
• perforation, hearing loss, mastoiditis, cholesteatoma, meningitis
• see guidelines for frequency, age
• Speech audiometry showing hearing loss, tympanometry shows flat response
• Tympanogram can prove to parents the ear is normal
• Grommets are first line tubes, last 6 to 24 months
• Butterfly tubes last 1-3 years
• T-tubes last longer
• The longer the tube is in, the greater the chance of perforation when they are removed.
• Tube otorrhea:
• Try drops first, work 80% of the time alone
• Show parents how to instill drops to make sure they get in the ear
• If drainage continues after 5-6 days let it drain a couple of days, then culture the pus and treat based on culture results
• If otorrhea persists refer back to ENT
• Sleep apnea complaints
• 2% of all children may have sleep apnea, 8-27% snore
• Sleep quality may be affected
• ADHD, school performance may be affected
• More sleep labs are willing to study children now
• With obese children with normal posterior OP try a sleep study. Consider CPAP, weight loss first
• If tonsils and adenoids are big then probably will get T&A, but of OSA persists then will need sleep study
• Most non-obese children are cured with T&A
• Post-operatively remember post-operative pulmonary edema (POPE), treated with lasix, limited fluids
• Prolonged cough unimproved with medical therapy
• Often noncompliant or give up on medications after a short trial
• Often have pan-sinusitis
• ENT docs may read sinus CT more conservatively, call less sinusitis than radiologists
• 50% of kids with no symptoms will still have sinus CT scans read as abnormal. ENT must correlate CT with clinical findings
• Prolonged amoxicillin (4 weeks) will often fix these kids
• The most common three problems with chronic cough are chronic under-treated sinusitis, allergy, asthma
• Consider culture, allergy testing
• If CT does not clear, consider evaluation for cystic fibrosis
• Sinus surgery is rarely indicated unless polyps are present or septum deviated
• Tonsillectomy/adenoidectomy is a last resort, rarely indicated

Duncan Phillips, MD

Surgeon in Chief, Wake Forest Medical Center

Surgical Cases

• Swollen scrotum in a 2 month old infant
• Normally the testicle should descend, internal ring should close
• Hydrocele is full of water, communicating hydrocele has a partial connection, hernia is fully open, may incarcerate
• Hydrocele should be observed for 1-2 years, usually close on their own but if persist need inguinal canal surgery
• Inguinal hernias are usuall indirect, failure of processus vaginalis to obliterate, affect 2-5% of babies, more common in males, affect 30% of premies
• Inguinal hernias do NOT resolve spontaneously, MUST be surgically closed
• Incarceration, strangulation are risks
• Complications in this group are very common, 31% incarcerate if you wait until 6 months to repair them
• Study in the early 1990’s demonstrated good results from operating once babies grew to be 2 kg in weight
• Repair is usually outpatient, performed under general anesthesia, without mesh repair
• RLQ abdominal pain with fever
• 7-8% of Americans will undergo appendectomy at some point in their lives
• Highest risk between ages 8 and 18 years
• Most common emergency abdominal surgery in the US
• Potentially fatal if untreated, easy to treat
• Missed appendicitis accounts for a large number of successful lawsuits against ED physicians
• Pain usually comes before any other symptom! Tends to be the Chief Complaint.
• Pain tends to be constant not intermittent, progressively worse, migrates from vague to RLQ, usually worse with movement or cough, usually does not have to be elicited.
• Vomiting is common, scraming is not, sudden motion tends to make it much worse.
• Do NOT check for rebound: that’s mean! Appendicitis will hurt on gentle palpation
• Mean WBC is 16.0, BUT range is 6.0 to 32.0. So a normal WBC is not all that reassuring.
• Call surgery for
• Classic case
• Persistent RLQ pain which is the dominant symptom
• Localized RLQ tenderness on gentle palpation
• Unclear cases
• Large reducible umbilical hernia in a four year old male
• Occur up to ten times more often in African Americans than in Caucasians
• Usually resolve in the first 1-2 years of life
• Consider repair at age 2-3 years if fascial defect is over 2.0 to 2.5 cm
• Incarceration is quite rare, about 1/3000 cases.
• Most repairs are done at age 4-5 years
• Most surgeons will leave the umbilical skin but close the defect

Sherry Ross, MD

Pediatric Urology, Duke University Medical Center

Urology, Common Referrals

• Asymptomatic bacteruria
• Two positive cultures with the same pathogen in a patient without symptoms (>100,000 CFU)
• If the urinary tract is normal there is no need to treat with antibiotics. They do fine on their own
• Children placed on prophylaxis had MORE infections than those who were observed, even in a population with some demonstrated renal scarring
• Afebrile UTI
• Positive culture with dysuria, frequency, etc. but WITHOUT fever
• Culture is positive with >100,000 CFU on clean catch, >50,000 on cath
• Look for voiding dysfunction, constipation in these kids, very frequently present
• Treat with sulfa, nitrofurantoin, cephalosporin. Amox and Augmentin have high resistance rates in these kids.
• Fix constipation before any other evaluation
• Febrile UTI (pyelonephritis)
• Fever, pyuria, positive urine culture
• Gold standard for diagnosis is DMSA scanning, cannot make the call on clinical and lab data alone with any specificity
• May use oral antibiotics in non-toxic children over age 3 months
• Must use IV antibiotics and hospitalize if toxic or under age 3 months
• PLEASE get a good urine specimen (cath or good clean catch) for culture and sensitivity
• Please send this information to pediatric urology on referral
• Old system was to check renal ultrasound and VCUG on all these kids, assuming all reflux is significant
• Newer diagnostic approach starts with DMSA scan, and if negative do NOTHING more. If positive go on to VCUG. If there is a second febrile UTI, then to VCUG regardless.
• Undescended testicle
• 4% of full term infants, 30% of preterm
• Usually fix by age 6 months if they will
• Examine sitting, which will often bring a testicle into the scrotum
• Ultrasound is a waste of time and money, DON’T bother!
• Relative risk of testicular cancer is 2.75 to 8, may be a little reduced if repaired
• Fertility rates may be somewhat decreased in these children even after repair, more impaired if both testicles undescended
• Phimosis
• Normal to age 3
• White cheesy stuff is normal, resolves with good bathing
• Pathologic when foreskin will not retract by age 3 years or there is a pinpoint opening, scarring
• Kidney Stones
• Seem to be on the rise in kids
• Push fluids
• Strain urine (coffee filter)
• Call MD if flu-like symptoms occur
• Duke now has a pediatric stone clinic, multi-disciplinary with nephrology, endocrinology, healthy lifestyles program

Victor Perry, MD

UNC Pediatric Neurosurgery

Chiari Malformation

• Type I cerebella tonsils displaced > 5 mm
• May occur with syrinx as well
• Present with suboccipital headache, weakness, spasticity, foramen magnum compression
• If asymptomatic and without syrinx can be followed clinically
• Type II
• Displacement of cerebellar vermis
• Associated with hydrocephalus, myelominengocele, migrational abnormalities
• Present in infancy
• Often causes death
• Emergent surgery in 20%
• Start asymptomatic, progress by age 3 months
• Swallowing problems, apnea, other dysfunctions of cervical spine function, stridor, vocal cord paralysis
• Two more types, quite rare
• For type I must rule out normal pressure hydrocephalus
• Check MRI and CT

Laura Enyedi, MD

Pediatric Opthalmology, DUMC

• Failed vision screen on Kindergarten Health Assessment
• Begin at age 3
• Refer if unable to test or if fails
• Photoscreening is not a substitute for vision testing
• Pay stinks for this code
• Infant vision develops from almost nothing at birth to pretty good at age 6 months. Macula has to develop.
• Should fix and follow by 3 months to 3 years
• Older than 3 years they need to tell you about pictures or letters
• Newborns should wince to light
• Test fixing and following 3 months to 3 years
• Check cover-uncover - may freak out when you cover one eye but not the other, a red flag
• Use a small fixation target, move it slowly
• Look for nystagmus, smooth pursuit
• Should be maintained when you uncover
• Use the most sophisticated test possible for the child’s developmental age
• Use a patch to cover the eye to avoid cheating on the monocular vision test
• Photoscreening in small children is useful, but does not test visual function
• Amblyopia occurs as a developmental process in the brain, not organic eye diease. Striate cortex fails to develop normally.
• Affects 2-4% of the population
• Over 1/2 develop severely impaired vision
• If the good eye gets injured then there’s a real problem
• Often results from a physical disruption of the visual axis like cataract, ptosis, or hemangioma
• Strabismus
• 50% of these kids have amblyopia, and 50% of amblyopic kids develop strabismus
• If one eye is suppressed you get amblyopia
• If both alternate you get decreased binocular vision
• Optical Defocus
• Hyperopia, Myopia, Anisometropia, Astigmatism
• Hyperopia is normal in young children, but it’s important both eyes accommodate the same
• Early referral is important, as the visual tracts mature by age 7 in many kids
• Esotropia
• Pseudostrabismus
• Decreased epicathal folds obscure the thie parts of the eyes.
• Look for light reflex
• Congenital
• Presents before age 6 months
• Cross fixate
• Treat with early surgery
• Not subtle, large-angle deviation
• Acquired
• Usually accommodative
• Toddlers to preschool
• May start intermittent
• Treat with glasses
• Patching for amblyopia
• Sometimes also require surgery

Patricia Morgan-Glenn, MD

Associate Medial Director

Child Maltreatment, Levine Children’s Hospital

Failure to Thrive

• Term has been officially changed to growth failure or growth delay
• Deceleration to a point below the 3rd percentile or deceleration more than two percentiles over a short period
• Most common during infancy
• Affects as many as 5% of American children
• Increased incidence in children with poverty, on Medicaid, in rural areas
• Incidence is increasing in middle class and upper middle class families as a result of panic over obesity
• Neglect is a rare cause, malnutrition is much more common
• Familial factors
• Developmental delay
• Cystic fibrosis
• Lactose intolerance
• familial short stature
• Psychosocial stressors
• Psychological issues
• Substance abuse
• Eating disorders
• Perinatal issues
• Preterm or low birth weight
• Intrauterine growth retardation
• In-utero drug exposure
• Placental insufficiency
• Post-natal factors
• Enzymatic
• Endocrine
• Metabolic
• Nutritional
• Psychosocial
• Is energy intake adequate? Is energy use inadequate? Is there excessive metabolic demand?
• Inadequate intake
• Mechanical problems - cleft palate, small chin, poor suck
• Poor tone
• Decreased appetite
• Respiratory problems
• GI disease, dysfunction
• Congenital heart disease
• Inadequate use of energy
• Vomiting
• Inadequate digestion
• Malabsorption
• Excessive losses
• Excessive metabolic demands
• Malignancy
• HIV
• CV disease
• Inflammatory condition
• Renal failure
• Hyperthyroidism
• Organic
• 5-25% of cases are due to an underlying medical condition
• Non-organic (neglect) is quite rare
• But many patients have a combination of both types
• Celiac disease should be high on your differential
• Dental problems, renal tubular acidosis among others to think of
• To diagnose non-organic FTT observing the feeding and parenting process is key, may require hospitalization or home visits
• Look for poor parenting skills, “What’s your perception of your child?”
• Ask, “How do you feel like your child is eating?” What they say may be very revealing.
• Observe feeding if at all possible.
• What are child-parent interactions like?
• Are there drug/mental health issues in the home?
• What social support is present for the parents?
• Look for intentional food withholding, bizarre health beliefs, resistance to your interventions. Consider DSS referral, hospitalization in these cases
• Normal growth: regain birth weight at 2 weeks, double birthweight at 4-6 months, triple birthweight by 12 months
• Growth Charts
• First used in 1977
• Weight curve is the strongest predictor of mortality, morbidity
• Weight for height: acute and recent nutritional deprivation
• Height for age: cumulative effects of chronic malnutrition
• For pre-term infants plot corrected age or use a pre-term growth chart
• Premies should catch up by
• weight by 24 months
• length/height b7 40 months
• head circumference by 18 months
• These standards may not apply to the extremely premature infant
• The first few months of life reflect uterine environment, not genetics
• History
• Get parent’s perception: they may not perceive a problem
• Focus on prenatal problems such as tobacco, alcohol, drugs, medication, placental or uterine problems
• Check PMH, Developmental history, GI ROS, sleep patterns, travel history, family history, psychosocial history
• Diet history is important
• Formula, supplements, 24 hour intake, change from breast milk to formula
• Who feeds the child?
• How is behavior during feeds?
• Get a three day food diary
• How long do feeds take?
• “What is a typical meal for your child?”
• Physical examination
• Vital signs and growth parameters
• Is the child thin, dehydrated?
• Is the face dysmorphic or flat affect? Hair thin? Eyes sunken? Teeth carious? Gums healthy?
• Skin changes or rash?
• Heart murmur?
• Edema or ascites, liver enlargement?
• Delayed social or developmental skills? Abnormal neurologic function?
• Studies/Evaluation - often all negative, so use a stepwise approach rather than a shotgun
• CBC, CMP, Liver enzymes, including Pre-Albumin
• Thyroid function tests
• Stool studies (fecal fat, O&P)
• Tissue transglutaminase, IgA
• Urinalysis and culture
• Calorie count
• Sed rate
• lead level
• HIV
• Sweat chloride
• PPD
• Growth factors
• Outpatient management
• Serial visits for weight and caloric intake evaluation (weekly is pretty standard)
• Get a food diary that covers 3 to 7 days of food intake
• May need to use home health or early intervention to keep families from having to pay too many copays or spend too much time in your office.
• Home visits are critical when they are available in your community. You may have to explore your options with DSS, home health nursing, etc.
• Normal calorie counts
• 0-6 moths of age 100-110 kcal/kg/day
• 6-12 months of age 100 kcal/kg/day
• But to catch up a child will need 120 kcal/kg/day
• You will probably have to step up caloric intake gradually, rather than suddenly
• If an infant is taking solids, see if caloric density is less than milk/formula then change to formula
• NO JUICE!
• High density formulas or fortifiers may help
• Multivitamin supplements with iron are helpful
• Add cheese, peanut butter, sour cream, butter to foods
• Consider referral to GI, cardiology, or nephrology depending on needs
• Utilize dietitian, speech therapy
• In severe cases NG feeds may be the solution, can work miracles in some cases
• Inpatient management
• Stays are usually under a week now
• If severely malnourished or concern for neglect then admit
• Obviously if acutely ill they should go in
• If failed outpatient management
• If you have to call DSS be prepared to make a very strong case, suggest a trial outside of mom’s care to see how the child does. Don’t ask them what they think, tell them what you think.
• Consequence of FTT
• Short term cognitive delay
• Not clear there is long term cognitive delay based on current literature
• Irritability
• Apathy
• Emotional/behavioral problems