Multifactorial Conditions of Failure to Thrive

Multifactorial Conditions
of Failure to Thrive: A
Case Study
Renée Guida
MSPH/RD Candidate
Johns Hopkins Bloomberg School of Public Health

Overview
 Review of the Literature
 Conditions of Failure to Thrive in Adult
 Introduction to Case Study Patient
 Nutrition Care Plan
 Initial Assessment
 Progress Check-in
 Follow-up
 Diet Education & Diet History PTA
 Progress Check-in
 Future Prognosis

Infection/Leukocytosis
• Malignant
fever, weight loss, fatigue
• Non-malignant
emotional stress,
rheumatoid arthritis
Organ Failure
• Chronic
pancreatitis
• Cirrhosis
DepressionPhysical Decline Cognitive Impairment Malnutrition
Anorexia Nervosa
AlcoholismAdult Failure To Thrive Underlying Psychiatric Disorders
Failure to Thrive
1,2,3,4,5

Infection
Laboratory findings
can indicate
presence of
infection through
elevated white
blood cell count. 6
Leukocytosis: a sign
of illness and is
recognized as a WBC
count > 11,000 cubic mm.
 Malignancy
 Non-Malignancy
White Blood Cell Normal
Differential
Percentage
Neutrophil 40-70%
Lymphocytes 24-44%
Monocytes 2-11%
Eisoniphils 1-4%
Basophils 0-2%

Organ Failure
CHRONIC PANCREATITIS
oOccurs in individuals 33-55 years 7
oOften caused by chronic alcohol
consumption
oOther causes: gallstones, trauma, viral
infections, biliary tract diseases,
hypertriglyceridemia and hypercalcemia8
CIRRHOSIS OF THE LIVER
oOccurs in 15% individuals with chronic
alcohol abuse > 10 years
oOther causes: hepatitis B or C9

Chronic Pancreatitis
• Dysfunction that leads to
dysregulation of glucose
homeostasis and digestion of
food
• May cause malabsorption and
lead to suboptimal nutrition
status
• Symptoms triggered by meal
consumption:
• Epigastric pain
• n/v8

Cirrhosis of the Liver
o Hepatotoxicity causes chronic
swelling and inflammation that
cause tissue to become necrotic,
forming irreplaceable scar tissue
oDiminished function leads to
nutrition implications
o Malabsorption  Malnutrition9

Symptoms
oMuscle wasting
oEdema
oJaundice
oBruising
oAscites
oAltered hair distribution
oPortal hypertension
oEsophageal varices
oEncephalopathy
oAltered colored urine and
stool
oGlucose intolerance and
hypoglycemia
oMalnutrition9
Individuals with n/v, inadequate oral intake, anorexia, and diet restriction exacerbate cirrhosis-related malnutrition

Nutrition Assessment Category Indicators of Diagnosis (one or more)
Anthropometric Measurements BMI <18.5
Failure to thrive
Unintentional weight loss >20% in 1 year, >10% in 6
months, >7.5% in 3 months >5% in 1 month, or >1 to
2% in 1 week
Nutrition-Focused Physical Findings Loss of subcutaneous fat
Increased muscle loss
Localized or generalized fluid accumulation
Food/Nutrition Related History Estimated energy intake <50-75% of estimated or
measured RMR
Unable or unwilling to eat sufficient energy/protein to
maintain a healthy weight
Excessive consumption of alcohol or other drugs that
reduce appetite
Food avoidance and/or lack of interest in food10
Malnutrition

Anorexia Nervosa
CHARACTERIZATIONS
 Food restriction and voluntary starvation
without binging or purging techniques,
such as vomiting or excess use of diuretics
Underweight BMI <18.5 kg/m2
Body weight <85% IBW
Compulsive behavior: ~ 50-75%
individuals diagnosed also suffer from
severe depression and OCD10
CONSEQUENCES
Contributes to malnutrition through
depletion of nutrient stores
Leads to weight loss
Up to 8% die from malnutrition,
dehydration or heart failure secondary to
electrolyte imbalances10

Metabolic Adaptations of Starvation
Early Fasting
Prolonged Starvation
Refeeding

Stages of
Starvation
I: Insulin  glycogen synthesis
II: Hepatic glycogenolysis
III: Hepatic gluconeogenesis;
muscle decreases uptake of
glucose, protein breakdown
provides precursors for
gluconeogenesis
IV: Brain and RBC utilize
ketone bodies, muscle wasting
and severe weight loss11

Refeeding
Initiation of feeding after prolonged period
of starvation
Glucose metabolism forces electrolytes
such as potassium, magnesium and
phosphorus into intracellular space,
decreasing serum levels.12
Reduction of salt and water excretion
from kidneys, leading to fluid overload.
Refeeding syndrome: metabolic
disturbances in individuals who are
malnourished, starved, or with chronic
illness.
Individuals at risk for refeeding syndrome:
1. BMI <18.5
2. Unintentional weight loss >10% in
previous 3-6 mos.
3. Little or no nutritional intake >5 days
4. Hx of alcohol abuse or drugs, including
diuretics

Refeeding Syndrome
Consequences:
Hypokalemia
Hypomagnesemia
Hypophosphatemia
Thiamine Deficiency12
Salt and water retention10
Hyponatremia
Heart and pulmonary complications13

Feeding and Management
Feeding should occur slowly
Calorie goals should be reached within 1 week after feeding depending
on patient’s level of malnourishment
Protein requirements recommended to be between 1.5 – 2 g/kg of body
weight to promote anabolism
Repletion of electrolytes and MVI through supplementation either
intravenously or through oral or powder tablets10

Characteristics and Social History
Age: 56 y.o
Gender: Female
Social History:
Current smoker; 5 cigarettes daily for the past 20 years
Hx of alcohol abuse; 1 bottle of wine per day since early 1990s
Son and daughter buy groceries and cook for pt who lives alone
Admission:
Presented to JHBMC Emergency Department from an outside hospital for rheumatologic care with
evidence of UTI, weakness, joint pain, and n/v
Pt was contracted upon admission and unable to keep fluids down
Admitted with failure to thrive, malnutrition, anorexia nervosa-restricting type, and rheumatoid
arthritis.
Chief concern: leukocytosis

Past Medical History
Total bilateral
knee
replacement
PEG placement r/t
anorexia nervosa and
inability to feed self  30
lb. weight gain
PEG removed  non-
healing gastrostomy site
w/ evidence of fistula
Total parenteral
nutrition initiated for
fistula repair and d/c
Per family, 15 lb.
weight loss in 2.5
months after d/c of
nutrition support

Active Problem List
oCirrhosis
oHyponatremia
oFailure to Thrive
oMalnutrition due to starvation
oAnemia
oAnorexia nervosa, restricting type
oAlcohol dependence
oAbdominal pain
oDepression
oAdjustment disorder with disturbance of
emotion
oOsteoarthritis
oAlcohol-induced chronic pancreatitis
oGeneralized weakness
oRheumatoid arthritis flare
oFever
oUrinary tract infection with pyuria

Physical Exam
PHYSICAL EXAM FINDINGS
Tachycardia
Malnutrition evidenced by sunken eyes
and temporal wasting
Both lower extremities contracted at
knees and tender to palpitation w/ stigmata
of erosive joint disease and rheumatoid
arthritis
Retarded psychomotor functioning with
depression and blocked thought
disturbance
TEST/PROCEDURE RESULTS
Calcification along pancreas, distention of
gallbladder and presence of calculi
Small bowel contained thickened loops w/
evidence of osteonecrosis
Kidneys found to have symmetric bilateral
stranding, reflective of renal inflammation
or obstruction

Hospital Course
DAY 0
Pt presented to JHBMC Emergency
Department from outside hospital for
rheumatologic care
Presented with generalized weakness,
chronic joint pain, nausea and reported
poor appetite/oral intake in the few days
PTA
Leukocytosis
DAY 1
Pt admitted to the General Medicine Unit
Labs indicated signs of rheumatoid flare
Refeeding labs ordered

Hospital Course
DAY 2
Provider consult for malnutrition
Nurse Screen Risk consult for poor
appetite/oral intake x 5 days PTA
Pt seen and screened as high risk
DAY 3
Pan scan performed to confirm infection, rheumatologic illness or
oncologic/leukemic disease r/t spike in WBC
Hb lab close to 7g/dL, prompting transfusion and iron supplement
CT chest, abdomen, pelvis ordered for signs of malignancy
Rheumatology consult: biopsy of cervical lymph node to rule out
malignancy
Infectious Disease consult: CT scan of neck lymph nodes
recommended
Gastroenterology consult: EGD and suturing of fistula
Calorie Count Day 1 & 2 reviewed – (231 kcal, 6 g Pro)
K+ labs low: potassium chloride supplementation

Hospital Course
DAY 4
Pt underwent CT neck scan, showing
multiple mass lesions representing
metastatic nodes
Labs: Mg low; Mg supplementation
Low K+ resolved with supplementation
DAY 5
Pt continued to be monitored for
refeeding syndrome, anemia, and
hyponatremia
CT neck scan results discussed with pt

Hospital Course
DAY 6
Pt continued with hyponatremia,
normocytic anemia, and leukocytosis
Otolaryngology consult: recommended
core needle biopsy for concern for
lymphoma or leukemia
Pt labeled as poor surgical candidate
given malnutrition, liver cirrhosis, and
chronic prednisone use
DAY 7
Pt underwent neck lymph biopsy
Pt followed up by nutrition
Calorie counts reviewed revealing poor
PO intake
Education provided for increasing kcal
and protein intake

Hospital Course
DAY 8
Pt continued to be monitored closely
DAY 9
Results of neck biopsy demonstrated
malignant cells
Right neck lymph node positive for
metastatic carcinoma
Pt was seen by nutrition to assess
improvements in oral intake/appetite, but
pt denied nutrition at time

Hospital Course
DAY 10
Pt underwent blood transfusion given low
Hb
Pt cleared for discharge to sub-acute
rehab facility given decrease in WBC count
DAY 11
Pt discharged with plans for oncological
follow-up appointments pending a full
pathological report
Pt deemed a poor candidate for
chemotherapy due to underlying conditions

White Blood Cell (k/cu mm)
oChief concern was leukocytosis
oSignificant spike on day 3
oDecline close to top normal reference
range upon discharge

Neutrophils (%)
oHigh neutrophil differential percentage as
a result of elevated WBC
oEtiology: inflammation, infection,
malignancy

Sodium (mmol/L)
oHyponatremia upon admission
oPt with low Na levels throughout hospital
course
oEtiology: malnutrition, cirrhosis,
dehydration

Chloride (mmol/L)
oPt admitted with low chloride levels but
increased throughout hospital course
oEtiology: hyponatremia, metabolic
acidosis, excessive vomiting

Magnesium (mg/dL)
oPt admitted with electrolyte imbalance
oAt risk for refeeding syndrome
oMg supplemented day 1, 3, 5, 6, 8
admission

Phosphorus (mg/dL)
oPt at risk for refeeding syndrome
oPhosphorus levels remained WNL
throughout hospital course

Potassium (mmol/L)
oLow levels in first few days of admission
oPt at risk for refeeding syndrome
oSupplementation of Potassium chloride
oLevels WNL after day 4 admission

Hemoglobin (g/dL)
oPt anemic upon admission
oBlood transfusion when Hb reached 7
mg/dL
oHb remained low throughout hospital
course

Creatinine (mg/dL)
oFluctuated throughout hospital course
oEtiology: decreased muscle mass, diet,
overall stress

Inpatient Medications
Drug Indication Drug/Nutrient Interaction
Dronabinol (Marinol) Appetite Stimulant, Antiemetic Alcohol, antihistamines, diazepam, may
cause drowsiness.
Diazepam Antianxiety, skeletal muscle relaxant Caution w/ grapefruit/related citrus with
oral diazepam.
Lorazepam Antianxiety Caution w/ grapefruit/related citrus.
Fentanyl patch Analgesic, Narcotic, Opioid N/A
Ferrous sulfate 65 mg elemental iron Hematinic, antianemic, mineral
supplement, iron (Fe)
Take 1 hr. before or 2 hr. after bran, high
phytate foods, tea, caffeine, red grape
juice/wine, soy, dairy for better
absorption.
Folic acid tablet 1 m B complex vitamin, antianemic Inhibited by deficiency of vitamin B12,
vitamin C or Fe.
Heparin 5,000 units/mL injection Anticoagulant N/A
Hydroxychloroquine tablet 200 mg Antiarthritic N/A

Magnesium Sulfate Mineral Supplement Take fiber, Fol, or Fe supplement
separately by at least 2 hrs.
Mirtazapine Anti-depressant St. John’s Wort
Morphine Analgesic, Narcotic, Opioid Avoid alcohol.
Multivitamin Vitamin/minerals supplement N/A
Ondansetron Antiemetic, antinauseant N/A
Oxycodone Analgesic, narcotic Caution w/ grapefruit/related citrus.
Pantoprazole Antigerd, antisecretory May decrease absorption of Fe and
Vitamin B12. Ca++ advised. Ca Citrate
better absorbed.
Potassium chloride Low K+ N/A

Prednisone Corticosteroid May decrease Na and increase Ca,
Vit. D, Protein. Caution w/
grapefruit/related citrus. Limit
caffeine.
Sennoside-docusate Stimulant laxative, stool softener May cause electrolyte imbalance w/
excessive use.
Simethicone Antiflatulent N/A
Sodium Chloride tablet Low sodium N/A
Sulfasalazine Anti-inflammatory/rheumatoid
arthritis
N/A
Thiamine B-complex vitamin def. r/t chronic
alcohol abuse
Alcohol inhibits absorption and
increases risk for deficiency.
Vancomycin Antibiotic Caution with decreased renal
function.

Initial Nutrition
Assessment
Reason For Referral: Poor
Appetite/Oral Intake x 5 days
PTA; Malnutrition
Referred By: Provider
Consult; Nurse Screening
Patient’s Nutrition Risk: High
Risk
Day 2 Admission
Anthropometrics:
Ht: 1.68 m (5’ 6”)
Weight: 35.5 kg (78 lbs) – 60% IBW
Wt change: Pt reported ~7 lb. unintended weight loss of unknown time
period
UBW: 105 lbs - 81% IBW
IBW: 130 lbs.
BMI: 12.6 kg/m2 -
Nutrition Information:
No Known Food Allergies
Current Diet: Heart Healthy (2g Na, 200 mg chol)
Nutrition Focused Physical Findings: Pt is malnourished; evidence of
temporal wasting and contraction at knees. Pt unable to stand. Pt
missing back teeth that makes it difficult to chew food sometimes.
Estimated Energy Needs:
Calories: 1256 kcal using Mifflin St. Jeor (966) x 1.3; equates to 35
kcal/kg
Protein: 53 g using 1.5 g/kg

Initial Nutrition
Assessment
Day 2 Admission
Nutrition Assessment:
o Pt reported symptoms of n/v in last 2 weeks PTA
oLast PO intake was on day 1 admission per pt
o Pt c/o vomiting on day of visit but was able to eat bite-size piece of toast
and several sips of water at bedside
o Pt unable to feed self
oPt unable to give specifics of diet history PTA
PES Statements:
“Malnutrition related to PMH of anorexia nervosa and pt reporting poor
appetite and nausea as evidenced by a BMI of 12.64 and observed
temporal wasting with contracted knees and pt reporting inability to stand
or extend knees.”
“Inadequate oral intake related to poor appetite and pt report of nausea as
evidenced by pt reporting a decreased PO intake in the last 2 weeks and
observed intake of small bite of toast at breakfast.”

Initial Nutrition
Assessment
Day 2 Admission
Interventions/Recommendations:
1. Adjust to regular diet. Encourage PO intake.
2. Recommend Magic Cup TID – any flavor (provides 290 kcal, 9 g Pro
per serving).
3. Recommend Ensure Enlive Strawberry once daily (Provides 350 kcal,
20 g Pro per serving); increase to TID if pt likes
4. Recommend MVI. Recommend Mg. Continue thiamin and folate.
5. Continue bowel regimen; consider adjusting Zofran to scheduled
provision rather than prn.
6. Pt requires assistance r/t weakness.
7. Start 48 hr. calorie count
Monitoring and Evaluation / Goals:
1. Weight trends (favorable weight trends)
2. Diet intake/tolerance (optimal nutrition intake)
3. Bowel function (bowel regularity)
4. Nutrition related labs (lytes WNL)

Progress Check-in
Calorie count day 2 admission reviewed – 25% single soda
Pt reported she was feeling better with no symptoms of n/v
Pt consumed iced tea and whole milk at bedside (would provide 138 kcal, 7 g Pro if
100% consumed).
Pt expressed interest in foods that were entered into CBORD
Pt reported dislike towards Ensure Enlive; requested it be d/c
Day 3 Admission

Follow-up
Nutrition
Assessment
Pt’s nutrition risk: High
Day 7 Admission
Progress towards previous goals:
o Pt c/o symptoms of n/v, altered tastes and smells, and abdominal pain
with decreased appetite and no improvements in PO intake.
o No new weight obtained since last initial assessment.
o Pt reported enjoyed soup and willing to try Unjury chicken flavor with
warm water.
o Pt reported consuming 1 small bite of apple pie on day of visit.
o Calorie Counts Reviewed Day 3-5
Energy needs: 1256 kcal, 53 g Pro
Assessment: Pt was NPO for neck biopsy
PES statement:
“Inadequate oral intake related to symptoms of poor appetite, nausea and
vomiting as evidenced by 72 hour documented calorie count of ~163 –
551 kcal/day (meets 13-44% kcal and 12-37% Pro estimated needs).

Calorie Counts Day 3- 5 Admission
Admission Day Kcal Protein % Kcal Needs % Pro Needs
3 278 6.5 g 22% 12%
4 551 14.1 g 44% 37%
5 163 6.5 13% 12%
* Day 2 admission calorie count revealed consumption of 25% of single soda

Follow-up
Nutrition
Assessment
Day 7 Admission
Interventions/Recommendations:
1. Continue Regular Diet
2. Recommend Unjury chicken flavor BID; if pt likes, advance to TID
(provides 100 kcal and 21 g Pro per serving). Continue Magic Cup
TID and change flavor to orange (provides 290 kcal and 9 g Pro per
serving).
3. Continue Ferrous sulfate, folic acid, thiamine, MVI, Mg sulfate,
Phytonadione, and potassium chloride.
4. Continue bowel regimen
5. Pt requiring mealtime assistance
6. Continue to closely monitor and replete refeeding lytes prn
7. Obtain new weight; monitor twice weekly
8. Continue daily calorie counts
9. Continue prn Zofran; adjust to scheduled dose if indicated
Monitoring and Evaluation (Goals)
1. Diet intake (optimal nutrition intake)
2. Weight trends (favorable weight trends)
3. Bowel function (bowel regularity)
4. Nutrition related labs (achieve nutrition related labs WNL)
5. Pt understanding of diet (understands diet recommendations)

Diet Education
Handouts: AND NCM High Calorie, High Protein Nutrition Therapy and Suggestions for
Increasing Calories and Protein handouts and JHBMC Smoothie Recipe
Reviewed:
Importance of increasing kcal and protein to ensure proper nourishment and weight gain
Tips for increasing intake to 6-8 small, frequent meals per day
Examples of foods pt can eat at home for n/v
Barriers: Pt engaged but frequently distracted and changed subject. Pt reported being
anxious and feeling unwell.
Comprehension: Fair due to distractions and psychological state; expected compliance
was poor
Day 7 Admission

Diet History PTA
INITIAL ASSESSMENT
3 meals per day prepared by daughter
and son with snacks in between
Pasta dishes and pretzels for snacks
FOLLOW-UP
Did not adhere to regular eating schedule
r/t symptoms of n/v
Unable to remember intake before
symptoms of n/v PTA
Usual intake of peanut butter with
crackers, potato chips, ground beef in any
kind of sauce
Gatorade

Progress Check-in
Attempted follow-up to assess PO intake
Pt refused nutrition, stating she needed to rest
Per RN, pt continued with poor PO intake
Day 9 Admission

Future Prognosis
 Pt now deceased; passed away at a hospice care facility soon after discharge
 FTT multi-factorial and r/t cancer diagnosis, rheumatoid arthritis, malnutrition, anorexia
nervosa, alcohol induced chronic pancreatitis, and cirrhosis.
 Pt was scheduled for outpatient oncology appointment at Johns Hopkins Hospital in
July 2016.
 Poor candidate for chemotherapy r/t current state of malnutrition and exacerbated by
poor PO intake, pancreatitis and cirrhosis.
 Current psychological state and underlying conditions considered a significant barrier
to any diet compliance or optimization of nutrient intake/provision after discharge

References
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