Failure to Thrive

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Failure to Thrive

• Rafat Mosalli MD FRCPC FAAP

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Overview

• Definitions
• Diagnosis
• Treatment
• Outcomes

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Definition

• Failure to Thrive (FTT)
• Weight below the 5th percentile for age and sex
• Weight for age curve falls across two major
  percentile lines
• weight gain is less than expected
• Other definitions exist, but are not superior in
  predicting problems or long term outcomes

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FTT

• A sign that describes a problem rather than a
  diagnosis
• Describes failure to gain wt
• In more severe cases length and head
  circumference can be affected
• Underlying cause is insufficient usable nutrition
  to meet the demands for growth
• Approximately 25 of normal children will have a
  shift down in their wt curve , then follow a
  normal curve -- this is not failure to thrive

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Introduction

• Specific infant populations
• Premature/IUGR wt may be less than 5th
  percentile, but if following the growth curve and
  normal interval growth then FTT should not be
  diagnosed

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Types

• Organic (30)
• 2º to a disease process
• medical treatment needed for illness
• Non-organic (70)
• under feeding psychosocial disturbance
  requires a change in the childs environment
• Mixed

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More useful classification system is

• Inadequate caloric intake
• Inadequate absorption
• Increased energy requirements

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Etiology

• Inadequate Caloric Intake
• Incorrect preparation of formula
• Poor feeding habits (ex too much juice)
• Poverty
• Mechanical feeding difficulties (reflux, cleft
  palate, oromotor dysfunction)
• Neglect
• Physicians are strongly encouraged to consider
  child abuse and neglect in cases of FTT that
  dont respond to appropriate interventions

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Etiology

• Inadequate absorption
• Celiac disease
• Cystic fibrosis
• Milk allergy
• Vitamin deficiency
• Biliary Atresia
• Post-Necrotizing enterocolitis

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Etiology

• Increased metabolism
• Hyperthyroidism
• Chronic infection
• Congenital heart disease
• Chronic lung disease
• Other considerations
• Genetic abnormalities, congenital infections,
  metabolic disorders (storage diseases, amino acid
  disorders)

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Diagnosis

• Accurately plotting growth charts at every visit
  is recommended
• Assess the trends
• HP more important than labs
• Most cases in primary care setting are
  psychosocial or nonorganic in etiology

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History

• Dietary
• Keep a food diary
• If formula fed, is it being prepared correctly?
• When, where, with whom does the child eat?
• PMH
• Illnesses, hospitalizations, reflux, vomiting,
  stools?
• Social
• Who lives in the home, family stressors, poverty,
  drugs?
• Family
• Medical condition (or FTT) in siblings, mental
  illness, stature?
• Pregnancy/Birth
• Substance abuse? postpartum depression?

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Changes in growth due to FTT

• early finding
• weight
• late findings
• length
• head circumference

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Growth charts of an 8 month old boy with
Non-organic FTT
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Physical

• Wt, Ht, HC with the growth chart
• Systemic exam
• Signs of neglect or abuse
• Inappropriate behavior

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Physical

• Observe parent-child interactions
• Especially during a feeding session
• How is food or formula prepared?
• Oral motor or swallowing difficulty?
• Is adequate time allowed for feeding?
• Do they cuddle the infant during feeds?
• Is TV or anything else causing a distraction?

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Physical Indications ofNon-organic FTT

• Lack of age appropriate eye contact, smiling,
  vocalization, or interest in environment
• Chronic diaper rash
• Impetigo
• Flat occiput
• Poor hygeine
• Bruises
• Scars

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• Investigations

• Rule 1 ? if Hx exam is negative unlikely
  to find a cause
• Rule II ? NO FISHING
• Rule III ? Guided by finding Hx and exam.
• Initial work up CBC-d ESR
• Electrolyte profile
• Urine analysis
• Stool analysis
• Bone profile.
• Specific investigations.

A
B
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TREATMENT 1) Urgent problems e.g. electrolyte
, infection, dehydration. 2) Nutritional
rehabilitation catch up growth requirement.
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Goal is catch-up weight gain

• Most cases can be managed with nutrition
  intervention and/or feeding behavior modification
• General principles
• High Calorie Diet
• Close Follow-up
• Keep a prospective feeding diary-72 hour

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Management

• Energy intake should be 50 greater than the
  basal caloric requirement
• Concentrate formula, add rice cereal
• Add taste pleasing fats to diet (cheese, peanut
  butter, ice cream)
• High calorie milk drinks (Pediasure has 30 cal/oz
  vs 19 cal per oz in whole milk)
• Multivitamin with iron and zinc
• Limit fruit juice to 8-12 oz per day

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Management

• Parental behavior modifications
• May need reassurance to help with their own
  anxiety
• Encourage, but dont force, child to eat
• Make meals pleasant, regular times, dont rush
• May need to schedule meals every 2-3 hours
• Make the child comfortable
• Encourage some variety and cover the basic food
  groups
• Snacks between meals

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Indications for hospitalization

• Rarely necessary
• weight below birth weight at 6 wks
• signs of physical abuse
• failure of out-patient therapy
• Hypothermia, bradycardia, hypotension
• safety is a concern
• work-up needed for organic causes

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Management

• For difficult cases
• Multidisciplinary team approach produces better
  outcomes
• Dietitians
• Social workers
• Occupational therapists
• Psychologists
• NG tube supplementation may be necessary

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INFANT WHO HAS FTT
HISTORY AND PHYSICAL EXAMINATION
Organic Cause
Cause Not Obvious
Feeding Disorder or Behavioral or Psychosocial Et
iology
Laboratory Screening Tests
Investigation and Management as Indicated
Positive
Negative
Treatment Malnutrition and Multidisciplinary Servi
ces
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Prognosis of non-organic FTT Retardation (15
- 67) School learning
(15 - 67) Behavioral
disturbance (28 - 48) Persistent
disorders of growth increased
susceptibility to infection


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CONCLUSION 1) FTT is a SIGN only 2) The most
important diagnostic method is HISTORY
EXAM. 3) The important of Nutrition for the brain
development in the first 2 years of life.
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Top 6 take home points

1. Evaluation of Failure to Thrive involves careful
   HP, observation of feeding session, and should
   not include routine lab or other diagnostic
   testing
2. Nutritional deprivation in the infant and toddler
   age group can have permanent effects on growth
   and brain development
3. Treatment can usually occur by the primary care
   physician in the outpatient setting.

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Top 6 take home points

1. Psychosocial problems predominate as the causes
   of FTT in the outpatient setting
2. Treatment goal is to increase energy intake to
   1.5 times the basal requirement
3. Earlier intervention may make it easier to break
   difficult behavior patterns and reduce sequelae
   from malnutrition

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References

1. Block RW, Krebs NF. Failure to thrive as a
   manifestation of child neglect. Pediatrics 2005
   Nov 116(5)1234-7. From National Guidline
   Clearinghouse www.guideline.gov
2. Kirkland, RT. Failure to thrive in children
   under the age of two. Up to Date
   http//www.utdol.com/utd/content/topic.do?topicKey
   gen_pedi/2884typePselectedTitle629 version
   14.2, april 2006pgs 1-8.
3. Krugman SD, Dubowitz H. Failure to thrive.
   American Family Physician, sept 1 2003. Vol 68
   (5).
4. Kane, ML. Pediatric Failure to Thrive. Clinics
   in Family Practice. Vol 5, 2, June 2003, pages
   293-311.
5. Agency for Healthcare Research and Quality
   (AHRQ) Evidence report Criteria for Determining
   Disability in Infants and Children Failure to
   thrive. 72, pages 1-54. http//www.ahrq.gov/clini
   c/
6. Bauchner, H. Failure to thrive, in Behrman
   Nelson Textbook of Pediatrics, 17th ed, chapter
   35, 36 - 2004.
7. Rudolf M, Logan S. What is the long term outcome
   for children who fail to thrive? A systematic
   review. In Arch Dis Child 200590925-931.

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