Overview
Failure to thrive is failure to grow at the expected rate given the child’s age. Historically divided into organic and non-organic (environmental) causes. Perform investigations if non-organic causes are not suspected.
- Signs of a neglected chid
- Poor hygiene
- Malnourished
- Bruises etc.
- Investigations
- Complete metabolic panel
- Complete blood count
- Urinalysis
- Serum proteins
- Stool O&C (Ova and Cysts)
- Sweat Chloride
- Karyotype: if Turner’s is suspected
- Serology: for celiac disease
- Treatment of mild FTT (where neglect/abuse is not suspected)
- Manage the underlying cause OR provide parent education regarding proper feeding practice and amount of nutrition required based on the child’s age (child with FTT require 150% of daily needs until normal)
- One-week food diary
- Follow-up in one week
- Consult with nutritionist or specialist in complicated cases
- Treatment of moderate-to-severe FTT (also if outpatient management has failed OR if neglect/abuse is suspected)
- Observed feeding over 3-7 days. 100-20 kcal/kg/d (should gain 2 oz. /day)
- Labs and consults as necessary
- Parent education (if non-organic)
- Mandatory social services/child protective services if neglect/abuse suspected
- Frequent follow-up
Subtypes of FTT
- Inadequate caloric intake
- Incorrect preparation of formula
- Inadequate breastmilk intake
- Mechanic feeding difficulties (poor latching, poor suck reflex, congenital anomalies)
- Poverty
- Neglect
- Diets that are difficult to apply to young children (Fad diets)
- Inadequate absorption
- Celiac disease
- Cystic fibrosis
- Cow’s milk enteropathy
- Vitamin or mineral deficiency (e.g., scurvy, acrodermatitis enteropathica)
- Biliary atresia or liver disease
- Increased metabolism
- Hyperthyroidism
- Chronic infection/immunodeficiency
- Chronic disease (renal insufficiency)
- Malignant process
- Hypoxemia (CHD, Chronic anemia, lung disease)
- Defective utilization
- Down’s syndrome (has a specialized growth chart)
- Diabetes mellitus, type 1
- Metabolic disorders (Lysosomal storage disorders, Amino acid metabolism defects)
- Congenital infections
Misconceptions about FTT
- “Failure to thrive is most commonly due to neglect and malnutrition”
- While partly true worldwide, FTT is more commonly due to illness, parental misconception, or difficulty regarding proper feeding.
- “Failure to thrive can be diagnosed whenever a child crossess down percentiles”
- Not always. An estimated 25% of children younger than 2 will change percentiles. Most clinicians consider crosesing 2 major percentile lines to be indicative of FTT.
- “A diagnosis of failure to thrive necessitates admission for observation”
- Not always. Severe FTT and suspected cases of neglect should be admitted. Some mild cases where the cause can be identified can be sent home with proper instructions and followup
Common non-organic practices that can lead to FTT
| Practice | Why is it a concern for FTT |
|---|---|
| Worries whether food will run out before there is money to buy more | Food insecurity is a high risk for all the practices listed |
| Overdilution of a standard formula | Reduces caloric concentration |
| Using condensed milk to make formula | Condensed milk has inadequate protein, fat and calories to sustain growth |
| A former preemie on a standard formula before one year of age | Premature infants should be on a 22 calorie/ounce formula to a year |
| Cereal in bottle | Dilutes caloric densitay, may increase work of feeding, can decrease reflux |
| No vitamin/mineral preparation in former preterm who is also receiving cow’s milk | Lack of effective counselling. Preemies are prone to Vitamin D and iron deficiency. |
| Infrequent feeding | Lack of effective counselling. Inadequate caloric intake is common. |
History
A comprehensive Hx is essential to identify some of the more easily addressed (and common) causes of FTT
- Nutrition History
- Frequency of feedings/meals
- Formula used and proper use (if applicable)
- Breastfeeding practice (if applicable)
- Diet and types of food given
- Any other particular diet practices (for social, religious or cultural reasons)
- Social and Economic History
- Poverty (if so, educate on utilization of social programs)
- Family dynamics
- Other caregivers besides primary (need to be educated too)
- Daycare use
- Developmental History
- Fine motor skills
- Gross motor skills
- Social skills
- Obstetric History
- Gravida/para/abortus status of the mother (particulalry at the time of birth of the patient)
- Course of pregnancy including any general complications
- Infections
- Substance use
- EtOH use
- Use of cigarettes
- Neonatal History
- Gestational age at birth
- APGARS
- Birth percentiles
- Neonatal course
- Review of Newborn screening tests
- Past Medical History of the child
- GI Symptoms (vomiting, constipation, diarrhoea, dysphagia, stooling)
- H/O infections
- Current or recent medications
- Review of Systems
- As with all patients
Physical Exam
A comprehensive physical is mandatory, particularly focusing on systems of concern based on History
- Vitals
- Temperature
- Pulse
- Respirations
- Color
- Skin/hair
- Hair texture
- Nails
- Birth marks
- Rashes
- Hygeine
- Trauma/burns
- Head
- Circumference and size
- Fontanelles
- Frontal bossing
- Facies/dysmorphia
- Eye
- Conjunctiva
- Fundoscopic exam
- Pupils
- Ears
- Size
- Shape
- Position
- Otoscopy
- Mouth/pharynx
- Tongue
- Teeth/caries
- Gums
- Palate
- Breath odour
- Neck
- Shape
- Webs/redundant skin
- Massess
- Thyroid
- Chest
- Bowel sounds
- Shape
- Liver and spleen
- Umbilicus
- Genitalia
- General appearance
- Pelvic exam if abuse is suspected
- Extremities/skeletal
- Edema
- Digits
- Joints
- Spinal alignment
- Neuro
- Cranial Nerves
- Deep Tendon Reflexes
- Tone
- Suck/swallow response
- Psychiatry (Mental State)
- Appearance
- Activity
- Affect
- Behaviour towards caregiver
