👶📉 Infancy – Failure to Thrive (FTT)

📘 Highly Important for Pediatric Nursing, Community Health Nursing, GNM/BSc Nursing, NHM, GPSC, AIIMS, Staff Nurse Exams

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🔰 Definition:

Failure to Thrive (FTT) is a condition in infants and young children in which physical growth is significantly below expected standards for age and sex, primarily involving weight and, in severe cases, height and head circumference.

✳️ FTT is a clinical presentation, not a disease — it reflects an underlying issue in nutrition, absorption, metabolism, or psychosocial care.

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📊 Growth Criteria for FTT Diagnosis:

🟡 Weight consistently below the 3rd or 5th percentile
🟡 Weight-for-age or weight-for-length that drops by 2 or more percentile lines
🟡 Growth velocity (rate of weight gain) that is abnormally slow
🟡 Delayed head circumference (in chronic/severe FTT)

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🧭 Types of FTT:

Type	Cause	Examples
🟥 Organic FTT	Underlying medical/physical illness	Congenital heart disease, chronic renal failure, HIV
🟨 Non-Organic FTT	Environmental/psychosocial issues	Neglect, poverty, improper feeding, emotional deprivation
🟩 Mixed FTT	Combination of both	Mild GI issue + poor caregiving or stress in family

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🔎 Etiological Factors (Causes):

🟥 Organic Causes (Medical/Physical):

• Congenital heart disease
• Chronic infections (e.g., TB, HIV)
• Cystic fibrosis
• Gastroesophageal reflux (GERD)
• Chronic diarrhea or malabsorption
• Endocrine disorders (e.g., hypothyroidism)
• Inborn errors of metabolism (e.g., galactosemia)

🟨 Non-Organic Causes (Psychosocial/Environmental):

• Inadequate feeding techniques (wrong dilution, underfeeding)
• Poor parental knowledge or caregiver fatigue
• Maternal depression or postpartum psychosis
• Family violence, substance abuse
• Child neglect or emotional abuse
• Poverty, food insecurity

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⚠️ Risk Factors:

🔸 Premature or low-birth-weight infant
🔸 Multiple siblings with limited family resources
🔸 Teenage or single mothers
🔸 Parental mental illness or substance use
🔸 Institutionalized children

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🧬 Pathophysiology Summary:

Nutritional deficiency → ↓ calorie/protein intake → ↓ weight gain → altered immune function → developmental delays → emotional & behavioral changes

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📌 Clinical Features of FTT:

System	Features
🟧 General	Failure to gain weight, thin limbs, wasted buttocks
🟨 Skin	Dry, loose skin, pallor, skin breakdown
🟩 Neurological	Developmental delay, poor social responsiveness
🟦 Behavioral	Irritability, excessive sleep or apathy, poor eye contact
🟥 Feeding	Feeding difficulties, vomiting, refusal to eat, poor suck

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🧪 Diagnostic Evaluation:

🔬 Anthropometric Assessments

• Weight, length, head circumference
• BMI-for-age, weight-for-height percentiles
• Serial measurements & plotting on WHO Growth Charts

🔬 Laboratory Investigations (as per clinical suspicion):

• CBC (anemia/infection), ESR, CRP
• LFTs, RFTs, serum proteins
• TSH, Free T4 (thyroid function)
• Stool examination (for malabsorption)
• Urinalysis
• HIV ELISA, sweat chloride test (CF)

🔬 Developmental Screening Tools:

• Denver Developmental Screening Test (DDST)
• Trivandrum Developmental Screening Chart (TDSC)

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💉 Medical & Nutritional Management:

🔹 Hospitalization Indicated If:

• Weight < 60% of expected
• Severe dehydration or malnutrition
• Suspicion of abuse/neglect
• Failed outpatient management

🟩 Medical Management:

• Treat the underlying condition (infection, GERD, cardiac issue)
• Correct anemia, electrolyte imbalance
• Start calorie-dense feedings under supervision

🟨 Nutritional Interventions:

• Provide 1.5x to 2x basal calorie requirement
• High-protein, high-calorie formula or fortified breast milk
• Frequent, small-volume feedings
• Supplement with iron, zinc, multivitamins

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👩‍⚕️ Nursing Management:

🟩 Assessment:

• Complete history (birth, nutrition, family, psychosocial)
• Detailed feeding behavior (timing, position, type of food)
• Observe parent-child interaction

🟨 Intervention:

• Educate caregivers on:
  • Proper feeding techniques
  • Correct formula dilution
  • Weaning and complementary feeding
• Daily weight monitoring & growth chart plotting
• Provide structured feeding schedule
• Promote bonding (kangaroo care, eye contact)
• Involve social worker if needed

🟥 Follow-Up:

• Weekly weight checks until stable
• Monthly developmental monitoring
• Continuous nutritional counseling

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🧠 Complications If Untreated:

❌ Developmental delays
❌ Severe protein-energy malnutrition (e.g., marasmus)
❌ Immune suppression → recurrent infections
❌ Psychosocial deprivation
❌ Long-term cognitive impairment

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📚 Golden One-Liners for Revision:

🟨 FTT = Weight < 3rd percentile or crossing 2 percentile lines downward
🟨 Organic = Disease-related | Non-organic = Environment or care-related
🟨 Growth chart = best diagnostic & monitoring tool
🟨 Mixed FTT is most common in clinical practice
🟨 Nurse’s major roles: Education, feeding guidance, follow-up

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✅ Top 7 MCQs for Practice:

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Q1. What percentile is used to define FTT in infants?
🅰️ 10th
✅ 🅱️ 3rd
🅲️ 25th
🅳️ 50th
Correct Answer: 🅱️ 3rd

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Q2. Which of the following is an organic cause of FTT?
🅰️ Child neglect
🅱️ Improper feeding
✅ 🅲️ Congenital heart disease
🅳️ Maternal depression
Correct Answer: 🅲️ Congenital heart disease

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Q3. What is the most reliable tool to assess FTT?
🅰️ Urine test
🅱️ Blood culture
✅ 🅲️ Growth chart
🅳️ Skin fold thickness
Correct Answer: 🅲️ Growth chart

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Q4. A key symptom in FTT is:
🅰️ Obesity
🅱️ Jaundice
✅ 🅲️ Developmental delay
🅳️ Fever
Correct Answer: 🅲️ Developmental delay

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Q5. Nursing care in FTT includes all EXCEPT:
🅰️ Educating caregivers
🅱️ Encouraging structured feeding
✅ 🅲️ Using physical restraints
🅳️ Monitoring weight
Correct Answer: 🅲️ Using physical restraints

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Q6. Which vitamin supplementation is critical in FTT cases?
🅰️ Vitamin A
🅱️ Vitamin D
✅ 🅲️ Multivitamins including iron and zinc
🅳️ Vitamin K
Correct Answer: 🅲️ Multivitamins including iron and zinc

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Q7. Best way to ensure feeding compliance in non-organic FTT is:
🅰️ Strict hospital rules
🅱️ Sedatives
🅲️ Caloric restriction
✅ 🅳️ Parental counseling and support
Correct Answer: 🅳️ Parental counseling and support

💩👶 Infancy – Diarrhea

📘 Highly Important for Pediatric Nursing, Community Health Nursing, GNM/BSc Nursing, NHM, GPSC, AIIMS, Staff Nurse Exams

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🔰 Definition:

Diarrhea in infancy is defined as the frequent passage of loose or watery stools, usually three or more times in 24 hours, which may be acute or chronic and is often associated with dehydration and malnutrition.

✳️ Not every frequent stool is diarrhea – it must be unusually loose and exceed normal pattern for that infant.

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🧭 Types of Diarrhea:

Type	Duration	Causes
🟥 Acute Diarrhea	< 14 days	Viral (e.g., Rotavirus), bacterial, food infection
🟨 Persistent Diarrhea	≥ 14 days	Infection, malnutrition
🟩 Chronic Diarrhea	≥ 30 days	Malabsorption, lactose intolerance, celiac disease
🟦 Dysentery	Bloody diarrhea	Shigella, E. coli

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🦠 Etiological Classification:

🟥 Infectious Causes:

• Viruses: Rotavirus (most common), Norovirus
• Bacteria: E. coli, Shigella, Salmonella, Campylobacter
• Parasites: Giardia lamblia, Entamoeba histolytica

🟨 Non-Infectious Causes:

• Improper formula preparation
• Overfeeding
• Food allergies
• Antibiotic-associated diarrhea
• Congenital enzyme deficiencies (e.g., lactose intolerance)

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⚠️ Risk Factors in Infants:

🔹 Poor hygiene practices
🔹 Unsafe drinking water
🔹 Improper weaning practices
🔹 Malnutrition
🔹 Bottle feeding
🔹 Incomplete immunization (e.g., rotavirus)

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📌 Clinical Features of Diarrhea:

System	Signs & Symptoms
💧 GI Tract	Frequent loose/watery stools, foul smell, greenish/yellowish color
🧂 Dehydration	Sunken eyes, dry mouth, poor skin turgor, decreased urine output
🟦 General	Fever, vomiting, irritability, lethargy, weight loss
🚨 Severe	Hypovolemic shock, sunken fontanelle, delayed capillary refill

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📊 Assessment of Dehydration (WHO IMNCI Guidelines):

Severity	Key Signs
🟩 No Dehydration	Normal skin turgor, eyes not sunken, drinks normally
🟨 Some Dehydration	Irritable, thirsty, sunken eyes, delayed skin pinch
🟥 Severe Dehydration	Lethargy, unable to drink, very sunken eyes, weak pulse

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🧪 Investigations (If required):

• Stool examination (pus cells, ova, parasites)
• Stool culture (bacterial cause)
• Serum electrolytes (Na+, K+, Cl−)
• Blood urea, creatinine (if severely dehydrated)

Most cases are clinically diagnosed and treated empirically.

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💊 Medical Management:

✅ 1. Rehydration Therapy:

• Oral Rehydration Salts (ORS) – cornerstone therapy
• Give 75 mL/kg over 4 hours in “some dehydration”
• Continue ORS after each loose stool
• Zinc supplementation:
  • < 6 months → 10 mg/day × 14 days
  • ≥ 6 months → 20 mg/day × 14 days

✅ 2. Feeding During Diarrhea:

• Do not stop breastfeeding
• Continue usual diet; add soft, easily digestible foods
• Avoid sugary drinks and cow’s milk during acute phase

✅ 3. Antibiotics (Only if indicated):

• Dysentery: Ciprofloxacin, Cefixime
• Cholera: Azithromycin, Doxycycline
• Parasites: Metronidazole (Giardiasis)

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👩‍⚕️ Nursing Management:

🟩 Assessment:

• Monitor frequency, volume, color of stools
• Monitor signs of dehydration (skin, fontanelle, urine)
• Record input-output chart, daily weight

🟨 Interventions:

• Prepare and administer ORS correctly
• Educate parents on homemade ORS preparation (1L boiled water + 6 tsp sugar + ½ tsp salt)
• Encourage breastfeeding and appropriate feeding
• Ensure hygiene: handwashing, clean utensils
• Isolate child if infectious cause suspected

🟥 Parental Education:

• Continue feeding, recognize dehydration
• Proper food storage and safe water practices
• Avoid over-the-counter drugs or anti-diarrheals in infants

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🧠 Complications:

❌ Severe dehydration → Hypovolemic shock
❌ Electrolyte imbalance → seizures
❌ Malnutrition
❌ Recurrent infections
❌ Growth faltering

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📚 Golden One-Liners for Quick Revision:

🟡 Most common cause of infantile diarrhea = Rotavirus
🟡 ORS + Zinc = Gold standard treatment
🟡 Continue feeding and breastfeeding during diarrhea
🟡 Use of antibiotics is limited and specific
🟡 Assess dehydration by skin turgor, eyes, drinking ability

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✅ Top 7 MCQs for Practice:

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Q1. Most common cause of diarrhea in infants is:
🅰️ E. coli
🅱️ Shigella
✅ 🅲️ Rotavirus
🅳️ Giardia
Correct Answer: 🅲️ Rotavirus

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Q2. Key component of diarrhea management is:
🅰️ Antibiotics
🅱️ Antiemetics
✅ 🅲️ ORS
🅳️ Sedation
Correct Answer: 🅲️ ORS

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Q3. Zinc supplementation in infants <6 months is:
🅰️ 5 mg/day
✅ 🅱️ 10 mg/day
🅲️ 20 mg/day
🅳️ 30 mg/day
Correct Answer: 🅱️ 10 mg/day

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Q4. A sign of some dehydration is:
🅰️ Lethargy
🅱️ Unconsciousness
✅ 🅲️ Thirsty, irritable
🅳️ Urine retention
Correct Answer: 🅲️ Thirsty, irritable

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Q5. Which of the following is NOT advised in infant diarrhea?
🅰️ Continue breastfeeding
🅱️ Administer ORS
✅ 🅲️ Stop feeding
🅳️ Give zinc supplements
Correct Answer: 🅲️ Stop feeding

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Q6. ORS solution should be used within:
🅰️ 2 hours
🅱️ 6 hours
✅ 🅲️ 24 hours
🅳️ 48 hours
Correct Answer: 🅲️ 24 hours

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Q7. Which parasite commonly causes chronic diarrhea?
🅰️ Shigella
🅱️ Norovirus
✅ 🅲️ Giardia lamblia
🅳️ Vibrio cholera
Correct Answer: 🅲️ Giardia lamblia

🤮👶 Infancy – Vomiting

📘 Essential for Pediatric Nursing, Community Health Nursing, GNM/BSc Nursing, NHM, GPSC, AIIMS, Staff Nurse Exams

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🔰 Definition:

Vomiting in infancy is the forceful expulsion of stomach contents through the mouth, commonly due to feeding errors, infections, or congenital abnormalities.

✳️ Regurgitation ≠ Vomiting
Regurgitation is passive (normal in infants); vomiting is forceful and abnormal.

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🧭 Types of Vomiting in Infants:

Type	Description	Examples
🟩 Non-bilious Vomiting	Without bile; often due to overfeeding or GERD	Pyloric stenosis, milk intolerance
🟥 Bilious Vomiting	Greenish in color; bile present	Intestinal obstruction, malrotation
🟨 Projectile Vomiting	Forceful ejection; occurs in arcs	Hypertrophic pyloric stenosis
🟦 Functional Vomiting	Without organic disease	GER, overfeeding

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🧠 Common Causes of Vomiting:

🟩 Feeding-related:

• Overfeeding
• Improper feeding position
• Swallowing air
• Formula intolerance
• Introduction of solid food too early

🟥 Gastrointestinal Disorders:

• Gastroesophageal reflux (GER)
• Pyloric stenosis
• Intestinal obstruction
• Gastroenteritis
• Hirschsprung’s disease

🟨 Infections:

• Viral illness (rotavirus)
• UTI
• Otitis media
• Sepsis

🟦 Neurological / Other Causes:

• Increased intracranial pressure (ICP)
• Inborn errors of metabolism
• Food allergies
• Medication side effects

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⚠️ Danger Signs (Red Flags):

❌ Bilious or bloody vomitus
❌ Projectile vomiting
❌ Poor feeding, lethargy
❌ Dehydration signs
❌ Abdominal distension
❌ Fever or convulsions
❌ Weight loss

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📌 Clinical Features:

Feature	Observation
🟩 Mild	Occasional vomiting, no distress, active feeding
🟥 Moderate	Frequent vomiting, mild dehydration, irritability
🟨 Severe	Projectile/bilious vomiting, lethargy, sunken eyes, weight loss

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🧪 Investigations:

🧬 History & Physical Exam – timing, frequency, relation to feeding
🧪 Blood tests – CBC, electrolytes
🧪 Stool culture – for infections
🧪 Abdominal X-ray / USG – rule out obstruction, pyloric stenosis
🧪 Urine analysis – for UTI
🧪 Neurological assessment – if signs of ICP present

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💉 Medical Management:

✅ 1. Mild Vomiting:

• Reassure and observe
• Correct feeding technique and frequency
• Keep baby upright after feeding

✅ 2. Moderate to Severe:

• Rehydration therapy – ORS or IV fluids
• Antiemetics (if prescribed) – Ondansetron
• Treat underlying cause – e.g., surgery for pyloric stenosis, antibiotics for infection
• Withhold feeding temporarily during vomiting episodes, then restart slowly

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👩‍⚕️ Nursing Management:

🟩 Assessment:

• Vomiting characteristics (color, frequency, volume)
• Feeding history and technique
• Dehydration signs (fontanelle, skin turgor, urine)

🟨 Interventions:

• Keep baby in upright position after feeding
• Educate parents on burping technique
• Ensure ORS administration if advised
• Maintain intake-output chart
• Monitor for electrolyte imbalance and weight changes
• Use sterile feeding equipment and maintain hygiene

🟥 Parent Education:

• Difference between regurgitation and vomiting
• When to seek medical attention (bilious vomit, weight loss, persistent vomiting)
• Proper feeding habits (amount, position, frequency)

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🧠 Complications:

❌ Dehydration
❌ Aspiration pneumonia
❌ Electrolyte imbalance
❌ Malnutrition
❌ Metabolic alkalosis (e.g., in pyloric stenosis)

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📚 Golden One-Liners for Quick Revision:

🟡 Vomiting ≠ regurgitation – vomiting is forceful
🟡 Bilious vomiting = suspect obstruction
🟡 Projectile vomiting = classic of pyloric stenosis
🟡 GER = common cause of functional vomiting
🟡 Nurse must monitor dehydration and educate caregivers

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✅ Top 7 MCQs for Practice:

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Q1. Which of the following is a danger sign in infant vomiting?
🅰️ Spitting after feeding
🅱️ Passing normal stools
✅ 🅲️ Bilious vomiting
🅳️ Belching
Correct Answer: 🅲️ Bilious vomiting

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Q2. Projectile vomiting in an infant suggests:
🅰️ GER
🅱️ Milk allergy
✅ 🅲️ Pyloric stenosis
🅳️ Intussusception
Correct Answer: 🅲️ Pyloric stenosis

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Q3. Vomiting due to overfeeding is:
🅰️ Bilious
✅ 🅱️ Non-bilious
🅲️ Projectile
🅳️ Bloody
Correct Answer: 🅱️ Non-bilious

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Q4. First action in infant vomiting with mild dehydration:
🅰️ Give antibiotics
✅ 🅱️ Give ORS and observe
🅲️ Start IV fluids
🅳️ Do surgery
Correct Answer: 🅱️ Give ORS and observe

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Q5. Key difference between regurgitation and vomiting is:
🅰️ Vomiting is normal
🅱️ Regurgitation is forceful
✅ 🅲️ Vomiting is forceful; regurgitation is passive
🅳️ Both need hospitalization
Correct Answer: 🅲️ Vomiting is forceful; regurgitation is passive

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Q6. Which investigation confirms hypertrophic pyloric stenosis?
🅰️ Urine test
🅱️ Stool culture
✅ 🅲️ Abdominal ultrasound
🅳️ ECG
Correct Answer: 🅲️ Abdominal ultrasound

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Q7. Best nursing position after feeding a vomiting-prone infant:
🅰️ Supine
🅱️ Prone
✅ 🅲️ Upright for 20–30 mins
🅳️ Trendelenburg
Correct Answer: 🅲️ Upright for 20–30 mins