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FAILURE TO THRIVE
( FTT)
Atan Baas Sinuhaji
Sub Division of Pediatrics Gastroentero-Hepatology
Department of ChildHealth,School of Medicine
University of Sumatera Utara/Adam Malik Hospital
Medan
GROWTH
Increase in the
mass of body tissues
ABSABS--BIKA FKUSUBIKA FKUSU 22
Anthropometric measurement
Head
Circumference
Body
Lenght
Body
Weight
DevelopmentDevelopment
ABSABS--BIKA FKUSUBIKA FKUSU 33
SkillSkill
Anthropometric asessment
At the spesific time Repeated visit
44
Poor Poor
Malnutrition F T T
55
Table 1. WATER LOW’S CLASSIFICATIONTable 1. WATER LOW’S CLASSIFICATION
NORMAL WASTING STUNTED
WEIGHT/ AGE %100 70 70
WEIGHT/ HEIGHT %
HEIGHT/ AGE %
100
100
70
100
100
87
F.T.T
SUBOPTIMAL OF GROWTH
REPEATED VISIT
Malnutrition is Malnutrition is
the sine qua non of the sine qua non of
the failure to thrivethe failure to thrive
ABSABS--BIKA FKUSUBIKA FKUSU 88
the failure to thrivethe failure to thrive
MALNUTRITION
GENETIC
FTT
99
PSYCHOSOCIAL
Malnutrition : inadequate nutrients
CALORI / NUTRIENTSCALORI / NUTRIENTS
Intake
Stools Absorption
1010
Utilization
Basal
Metabolism
Peripheral Utilization
Growth
IMPAIRED OF
PERIPHERAL
UTILIZATION
BASAL UTILIZATION
NUTRIENTS
MALABSORPTION
INTAKE
1111
NUTRITION
INADEQUATE
MALNUTRITION
Etiology of growth disordersEtiology of growth disorders
1.1. Inadequate intake of Inadequate intake of calories/nutrients calories/nutrients
2.2. Excessive calories/nutrients Excessive calories/nutrients losseslosses
–– VomitingVomiting
4.4. Impaired of peripheral Impaired of peripheral utilizationutilization
–– Chronic infectionChronic infection
–– MalignancyMalignancy
1212
–– VomitingVomiting
–– MalabsorptionMalabsorption
3.3. Basal metabolismBasal metabolism
–– FeverFever
–– HyperthyroideaHyperthyroidea
–– HyperkinesiaHyperkinesia
–– InfectionInfection
–– Congenital heart Congenital heart diseasesdiseases
–– AnemiaAnemia
–– Inborn errorsInborn errors
–– HormonalHormonal
FTT CAUSED BY BOWEL DYSFUNCTION
INADEQUATE
CALORY INTAKE-QUALITY
-IGNORANCE
-ANOREXIA
EXCESSIVE CALORY LOSS
-VOMITING
-MALABSORPTION
-PROTEIN LOSING ENTEROPATHY
1313
ENTEROPATHY
INCREASED
NEED - FEVER
DISORDER OF DIGESTION
1414
MALDIGESTION
MALABSORPTION
MALABSORPTION
FAILURE OF THE DIGESTIVE SUBSTRACTS ACROSS LUMEN INTO
1515
MUCOSE
VESSELSBLOOD
LYMPH
MALABSORPTION
1.MALDIGESTION
2.HYPEROSMOTIC
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2.HYPEROSMOTIC
3.PERISTALSIS
4. ABSORPTION AREA- SHORT GUT
- MUCOSAL INJURY
MALDIGESTION
DISORDERS
INTRALUMINALMEMBRANE
INTRACELLULARE
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INTRALUMINALMEMBRANE
-GASTER
-PANCREAS
-LIVER-GUT →→→→ ENTEROKINASE
(trypsinogen trypsin)
- MALTASE
- LACTASE
- SUCRASE- GLUCOAMYLASE
•PEPTIDASE
•LIPASE
MUCOSAL INJURY
ENTEROCYTE
-LUMINAL MEMBRANE
-INTRACELL / CYTOPLASMA
TIGHT JUNCTION
1818
-INTRACELL / CYTOPLASMA
-BASOLAT. MEMBRANE
-BASAL MEMBRANE
INTERCELLULER SPACE
LAMINA PROPRIA
-BLOOD/LYMPH VESSELS
-SECRETION ↑
-MACROMOLECULAR ABSORPTION
SENSITIZATION
Causes of Causes of mumuccosaosal injuryl injury
1. Mucosal compromised
� Malnutrition
� Folic acid Deficiency
� Iron Deficiency
� Antioxidant Deficiency
2. Infection
ABSABS--BIKA FKUSUBIKA FKUSU 1919
2. Infection
� Viral (rotavirus)
� Bacteria overgrowth
� Antibiotica ( e.g. Neomycine )
3. Immunological disorder
� SIgA Deficiency
4. Parasitic Infestation
� Giardiasis
Consequences of Consequences of mumuccosaosal l
injuryinjury
1.1. DiarDiarrhorhoeeaa
2.2. MalabsorpMalabsorpttiionon
ABSABS--BIKA FKUSUBIKA FKUSU 2020
3.3. PProteinrotein losing enteropathylosing enteropathy
4.4. SensitiSensitizzaattiionon �� mamaccroro molemolecculeruler absorptionabsorption
5.5. NNeeccrotirotizing Enterocolitiszing Enterocolitis
CLASSIFICATION OF MALABSORPTION
1.SUBSTRACTS
2.SELETIVE/GENERALIZED
2121
3.OBTAINED –CONGENITAL--- ACQUIRED
4.PATHOPHYSIOLOGY
5.PATHOGENESE & ETIOLOGY
SUBSTRACT
CARBOHYDRATE
FAT
PROTEIN
WATER & ELECTROLYTES
2222
SUBSTRACT WATER & ELECTROLYTES
VITAMIN
MIXED OR GENERALIZED
I I
PAN MALABSORPTION
Pathogenese
& etiology
Congenital & genetic
Bacterial overgrowth
Bile acid def.
2323
& etiology
sensitization
nutritional
Drug induced
CARBOHYDRATE1. INTRALUMINAL ENZYME :
AMYLASE
2. BRUSH BORDER ENZYME
OLIGO/DISACHARIDASE
2424
3. ABSORPTION
4. COLONIC BACTERIA
•GLUCOSE
•FRUCTOSE
•GALACTOSE
SCFA
COLON NUTRITION
BOWEL NUTRITION
SMALL INTESTINE
COLON
2525
70% INTRALUMINAL30% INTRAVASAL
45% INTRALUMINAL55% INTRAVASAL
TRYGLYCERIDE
FATTY ACID GLYCEROL
SHORTCHAIN FATTY
2626
SHORTCHAIN FATTY ACID (SCFA)
MEDIUM CHAIN FATTY ACID (MCFA)
LONG CHAIN FATTY ACID (LCFA)
C<6
C=6-8(12)
C>12
DIGESTION & ABSORPTION OF FAT
1.EMULSIFICATION
2.LIPOLYSIS LIPASE
3.MICELLE BILE SALT
2727
3.MICELLE BILE SALT
4.ENTER INTO MUCOSE
5.RE-ESTERIFICATION
6.CHYLOMICRON
7.BLOOD/LYMPH VESSELS
MCT(MEDIUM CHAIN
TRIGLYCERIDE)
C=6-8(12)
2828
1.LIPASE 70%
2.NO BILE SALT
3.NO REESTERIFICATION
4.NO CHYLOMICRON FORMATION
5.PORTAL VEIN
DIAGNOSTIC OF FAT
MALABSORPTION
1. MICROSCOPIC
2. FLOATING TEST (ROSSIPAL)
3. LIPIODOL ABSORPTION TEST
2929
3. LIPIODOL ABSORPTION TEST
4. SERUM CAROTEN
5. FAT BALANCE (VAN DE KAMER)
6. STEATOCRITE
LIPIODOL ABSORPTION TEST
LIPIODOL FAT+IODINE
Drink of 5-10 mL
3030
BLOOD
URINE + AMYLUM 1%
DILUTION 1:1
1:2
1:8 (+) N
DIGESTION &
ABSORPTION OF
PROTEIN 1.INTRALUMINAL DIGESTION (HCL, PEPSIN)
3131
2.ACTIVATED PANCREATIC ENZYMES BY
ENTEROKINASE
3.PROTEOLYSIS →→→→PEPTIDE & AMINO ACIDS
4.MUCOSE →→→→ INTRACELLULER DIGESTION
5.PORTAL VEIN
MALABSORPTION
ACUTE CHRONIC DEF. ABD. DISTENSION
AVITAMINOSIS
3232
DEHYDRATION
- PERSISTENT DIARRHOEA- FAILURE TO THRIVE
AVITAMINOSIS
TREATMENT OF MALABSORPTION
1. ETIOLOGY-INFECTION
-ENZYMS
2. DIETPREDIGESTED FORMULA
3333
3. SUPPORTIVE- WATER & ELECTROLYTES- VITAMIN & MINERAL- PREVENTION OF MALNOURISHED
PREDIGESTED FORMULA
MALABSORPTION SYNDROME
1. LACTOSE INTOLERANCE
2. COW’S MILK PROTEIN INTOLERANCE
3. PCM
3434
4. CHOLESTASIS
5. PARASITIC INFESTATION
6. ANTIBIOTICS
7. POST ENTERITIS MALABSORPTION
TerminologyTerminology
Lactose Intolerance Lactose Intolerance
�� Lactase Defisiency : Lactase Defisiency : Lactase Defisiency : Lactase Defisiency : Lactase Defisiency : Lactase Defisiency : Lactase Defisiency : Lactase Defisiency : Low / absence activity of lactase Low / absence activity of lactase Low / absence activity of lactase Low / absence activity of lactase Low / absence activity of lactase Low / absence activity of lactase Low / absence activity of lactase Low / absence activity of lactase →→→→→→→→ enzyme assayenzyme assayenzyme assayenzyme assayenzyme assayenzyme assayenzyme assayenzyme assay
�� Laktose Malabsorption : Laktose Malabsorption : Laktose Malabsorption : Laktose Malabsorption : Laktose Malabsorption : Laktose Malabsorption : Laktose Malabsorption : Laktose Malabsorption : Failure of the small intestine to absorb lactose Failure of the small intestine to absorb lactose Failure of the small intestine to absorb lactose Failure of the small intestine to absorb lactose Failure of the small intestine to absorb lactose Failure of the small intestine to absorb lactose Failure of the small intestine to absorb lactose Failure of the small intestine to absorb lactose ��������
conformity with the testconformity with the testconformity with the testconformity with the testconformity with the testconformity with the testconformity with the testconformity with the test
3535
conformity with the testconformity with the testconformity with the testconformity with the testconformity with the testconformity with the testconformity with the testconformity with the test
�� Lactose Intolerance :Lactose Intolerance :Lactose Intolerance :Lactose Intolerance :Lactose Intolerance :Lactose Intolerance :Lactose Intolerance :Lactose Intolerance : clinical clinical clinical clinical clinical clinical clinical clinical
symptoms/signssymptoms/signssymptoms/signssymptoms/signssymptoms/signssymptoms/signssymptoms/signssymptoms/signs
LACTOSE
The Primary Carbohydrate Of
Mammals Milk
3636
Breast Milk
(7 %)Cow Milk
(4 %)
Sea Lion Milk
(0 %)
LACTOSELACTOSEGlucose &Glucose &
GalactoseGalactoseLactaseLactase
•• In outer of brush borderIn outer of brush border
3737
•• In outer of brush borderIn outer of brush border
•• Smallest amountSmallest amount
•• No adaptive enzymsNo adaptive enzyms
LACTASE LACTASE
PrimaryPrimary
DevelopmentalDevelopmental
Congenital alactasiaCongenital alactasia
Late onset hypolactasiaLate onset hypolactasia
3838
LACTASE LACTASE
DefisiencyDefisiency
SecondarySecondary Mucosal damage eg Mucosal damage eg →→
rotavirus diarrhoearotavirus diarrhoea
UNABSORBED LACTOSE UNABSORBED LACTOSE
OSMOTIC OSMOTIC OSMOTIC OSMOTIC OSMOTIC OSMOTIC OSMOTIC OSMOTIC ACTIONACTIONACTIONACTIONACTIONACTIONACTIONACTION
COLONCOLONCOLONCOLONCOLONCOLONCOLONCOLON
WATERWATERWATERWATERWATERWATERWATERWATER LACTOSELACTOSELACTOSELACTOSELACTOSELACTOSELACTOSELACTOSEABSORBEDABSORBEDABSORBEDABSORBEDABSORBEDABSORBEDABSORBEDABSORBED
FERMENFERMENFERMENFERMENFERMENFERMENFERMENFERMEN
TATIONTATIONTATIONTATIONTATIONTATIONTATIONTATION
GASESGASES
SHORT CHAIN FATTY ACIDSHORT CHAIN FATTY ACID
HH22
COCO22
CHCH44
3939
COLONICCOLONICCOLONICCOLONICCOLONICCOLONICCOLONICCOLONIC
SALVAGESALVAGESALVAGESALVAGESALVAGESALVAGESALVAGESALVAGE
•• OSMOTIC DIARRHOEAOSMOTIC DIARRHOEAOSMOTIC DIARRHOEAOSMOTIC DIARRHOEAOSMOTIC DIARRHOEAOSMOTIC DIARRHOEAOSMOTIC DIARRHOEAOSMOTIC DIARRHOEA
•• REDUCTION SUBSTANCE (LACTOSE) REDUCTION SUBSTANCE (LACTOSE) REDUCTION SUBSTANCE (LACTOSE) REDUCTION SUBSTANCE (LACTOSE) REDUCTION SUBSTANCE (LACTOSE) REDUCTION SUBSTANCE (LACTOSE) REDUCTION SUBSTANCE (LACTOSE) REDUCTION SUBSTANCE (LACTOSE) →→→→→→→→ CLINITESTCLINITESTCLINITESTCLINITESTCLINITESTCLINITESTCLINITESTCLINITEST
•• LACTAT ACID LACTAT ACID LACTAT ACID LACTAT ACID LACTAT ACID LACTAT ACID LACTAT ACID LACTAT ACID →→→→→→→→ stools pH stools pH stools pH stools pH stools pH stools pH stools pH stools pH →→→→→→→→ LACMUSLACMUSLACMUSLACMUSLACMUSLACMUSLACMUSLACMUS
L L -- LACTATELACTATE
DIAGNOSTIC OF LACTOSE INTOLERANCEDIAGNOSTIC OF LACTOSE INTOLERANCE
Lactose tolerance testLactose tolerance test
++
Lactose malabsorption testLactose malabsorption test
4040
Lactose malabsorption testLactose malabsorption test
a.a. Stools pH & clini testStools pH & clini test
b.b. Lactose loading testLactose loading test
c. Breath hydrogen testc. Breath hydrogen test
Stools pH & clini testStools pH & clini test
Screening TestScreening Test
4141
• Only drunk lactose
• Fast intestinal transit time
• Fresh stools
• Incomplete degradation of lactose
Breath Breath
hydrogen hydrogen
testtest
4242
••Night fastingNight fasting
••Doses of lactose : 2 Doses of lactose : 2 grgr//kgBWkgBW (max. 50 (max. 50
grgr) in concentration of solution 20 %) in concentration of solution 20 %
••Samples are then collected every 30 Samples are then collected every 30
minutes for 3 hours to determine Hminutes for 3 hours to determine H2 2
concentration in expired airconcentration in expired air
••MalabsorptionMalabsorption : > 20 : > 20 ppmppm greater greater
than fasting levelthan fasting level
TREATMENTTREATMENT
LACTOSE INTOLERANCELACTOSE INTOLERANCE
Primary Secondary
4343
1.1.Low/free lactoseLow/free lactose
2.2.PrematurePremature
-- Breast milk (+): continuedBreast milk (+): continued
-- Breast milk (Breast milk (--) : lactose lowered) : lactose lowered
+ glucose polymer+ glucose polymer
Breast milk continued
Breast milk (Breast milk (--)) ????
COW’S MILK PROTEIN INTOLERANCE
-SMALL BABY
-DIARRHOEA
-ENTEROPATHY
Lact. Intol. CMPI
>>> >1.FREQ.
4444
>>> >
(-) (+)
1.FREQ.
2.Extra GI Tract
manifestation
3.Phenomenon DOSE DEPENDENT DOSE INDEPEN.
Goldman CriteriaGoldman Criteria
1.1. Remission of symptoms after elimination Remission of symptoms after elimination of cow milk from the dietof cow milk from the diet
2.2. Relapse within 48 hours of beginning a Relapse within 48 hours of beginning a milk challengemilk challenge
4545
milk challengemilk challenge
3.3. Positive reaction to 3 such challenges Positive reaction to 3 such challenges (similar onset, duration, and clinical (similar onset, duration, and clinical features)features)
MUCOSAL
DAMAGE
BIOPSY
PERMEABILITY
4646
PROTEIN LOSING
ENTEROPATHY
-Dxylose absorption test
-L/M excretion ratio
-Polyethylen glycol abs. test
PROTEIN LOSING
ENTEROPATHY
MUCOSAL DAMAGE
INFLAMMATION
NONINFLAMMATION
4747
LYMPH OBSTR.
LYMPHANGIECTASIA
CHD*
*Congenital Heart Disease
DIAGNOSTIC OF PROTEIN LOSING ENTEROPATHY
1. ISOTOP
2. FECAL α1- ANTITRYPSIN
4848
