Has patient achieved normal developmental milestones

Developmental delays may provide clues to the cause of FTT. FTT itself can cause delay.

G. What is the past medical history? Hospitalizations, recurrent infections, and chronic diarrhea suggest chronic disease.

H. What medication(s) does patient take? Ask about prescribed, over-the-counter, and alternative remedies.

I. What is the social history? Specific questions include:

1. Who is primary caregiver?

2. Who lives at home?

3. Who cares for patient if caregiver is away?

4. Any changes in family dynamics?

J. Family history? Relevant information includes siblings or parents with chronic disease or recurrent infection, chromosomal or metabolic abnormality, fetal or infant deaths, and stature and growth trends, including FTT. K. Interaction among patient, caregiver, and family? FTT usually involves environmental or psychosocial factors, or both. Child maltreatment and neglect take many forms, from overt physical and emotional abuse to nonintentional neglect.

Differential Diagnosis. FTT is a sign, not a diagnosis. The cause of the undernutrition must be determined. Most patients are younger than 3 years of age. Often FTT may involve a combination of organic (ie, major disease process or single organ dysfunction) and environmental or psychosocial factors (ie, no distinct pathophysiologic abnormality but, rather, insufficient emotional-physical nurturing). Presence of one factor does not preclude a search for others.

A. Environmental, Psychosocial, or Nonorganic FTT. Most common type in the United States. Includes neglect (intentional, nonintentional), feeding issues (decreased amount, improper mixing of formula, poor technique), poverty (food unavailable), and parental incompetence (maternal depression, substance abuse, diminished mental capacity).

B. Congenital or Anatomic Anomalies. Chromosomal defect, congenital anomalies, cardiac defect, infection, cystic fibrosis, in utero exposure to toxins.

C. GI Abnormalities. Gastroesophageal reflux disease, milk-protein intolerance, celiac disease, Hirschsprung disease, irritable bowel disease, malabsorption, malrotation.

D. Renal Disorders. Occult UTI, renal tubular acidosis, chronic renal insufficiency.

E. Cardiac Disorders. Persistent patent ductus arteriosus, acquired heart disease, congestive heart failure.

F. Pulmonary Disorders. Bronchopulmonary dysplasia, poorly controlled asthma, chronic aspiration.

G. Infectious Diseases. HIV, tuberculosis, parasitic infestations, dental disease.

H. Metabolic Alterations. Inborn errors, galactosemia, amino or organic acidurias, storage diseases, hypercalcemia.

I. Endocrine Disorders. Thyroid, parathyroid, adrenal, pituitary, or growth hormone disorders; diabetes mellitus type 1. J. Neurologic Disorders. Degenerative disorders, cerebral palsy, oral motor dysfunction, structural defects. K. Medications. Prescribed, over-the-counter, and alternative remedies.

L. Other Causes. Malignancy, sickle cell disease, environmental toxins (lead).

IV. Database. Further evaluation (laboratory and other studies) is rarely useful unless suggested by history or physical exam findings.

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