Failure to Thrive
When Simple and Natural
Gets Complicated
“I’m a Failure to Mother”
• Be careful of pejorative
language – Parental
Deprivation Syndrome (1960)
• Primary need is to instill
confidence in the family
“I’m a Failure to Mother”
“Growth Deficiency”
• Weight based assessment
• Insufficient growth velocity
Weight
Height
Head Circumference
• Organic/Inorganic
Start at the Beginning
Uteroplacental Insufficiency
Maternal Hypertension
Diabetes Mellitus
Renal Disease
Collagen Vascular Disease
Genetics
Parental - Age
Fetal – Trisomy, Russell-Silver Syndrome
Maternal Nutrition - time dependant,
relatively resistant
Start at the Beginning
40% of Growth Deficient
infants are born with
birth weights of less
than 2500 grams
(5 pounds 8 ounces)
Start at the Beginning
During fetal period,
endocrine system has
little impact on growth.
Pituitary aplasia,
congenital
hypopituitarism or
growth hormone
insensitivity will have
NORMAL weight at birth
Normal Growth Variation
More than half of newborns
experience an upward shift of
growth during the first 3 months
30% of normal babies experience a
downward shift between the ages of
3 and 18 months
Children reach genetic length by 2
years
Many children have significant weight
decrease around between 9 and 15
months
Timing of Abnormality
Severe Anatomic
Abnormality
Severe Reflux
Heavy Metal
Poisoning
Protein Sensitivity
Infection – GBS,
TORCH
Deprivation
Breast Feeding Dysfunction
Chronic Reflux
Cardiac Anomaly
Cystic Fibrosis
Milder Anatomic
Abnormality
Birth
1 week 2-4 weeks
1 month
Inappropriate
Diet
6 months
9 months
1 year
Causes of Failure to Thrive
Inadequate
Input
Increased
Utilization
Excessive
Output
Humans are a Closed Energy System
text
CALORIES IN
METABOLIC USE
CALORIES LOST/
NOT USED
=
ZERO
Causes of Failure to Thrive
Inadequate
Input
Increased
Utilization
Excessive
Output
Inadequate Input
1. INSUFFICIENT NUTRITION OFFERED
2. MATERNAL/CHILD AXIS
DYSFUNCTION
3. PSYCHOSOCIAL DYSFUNCTION
4. SEVERE GASTROESOPHAGEAL
REFLUX / VOMITING
5. MECHANICAL PROBLEMS
6. SUCKING OR SWALLOW
DYSFUNCTION
Inadequate Input
INSUFFICIENT NUTRITION OFFERED
Maternal Medical Stress
Anti-histamines
Narcotics/Alcohol
Inappropriate or incorrectly constituted
formula
Displacement of nutritious offering by poor
nutritional component
Vitamin deficiency
Lead (5-35 mcg/dL) potentiated by poor
Calcium and Vitamin D
Inadequate Input
MATERNAL/CHILD AXIS
DYSFUNCTION
Inappropriate knowledge of infant/child diet
Sub-optimal feeding technique
Maternal depression
Poor bonding (NICU, illness, maternal
aversion, abuse)
Inadequate Input
PSYCHOSOCIAL DYSFUNCTION
25% of children in Tennessee live below the
poverty level
In Chattanooga 80% of African-American
children are born to single mothers
(poor social network)
Inadequate Input
PSYCHOSOCIAL DYSFUNCTION
Marital stress
Domestic violence
Parental employment
Children of mother’s under 18 have poorer
growth and twice as likely to
be
abused
Number and age of siblings/health of others
in the family
Homelessness or home instability/unstable
transportation
Inadequate Input
SEVERE GASTROESOPHAGEAL REFLUX
Poor intake
Pain feedback loop
VOMITING
Infectious gastroenteritis/post-vial ileus
Chronic pyelonephritis
Increased intracranial pressure
Cyclic vomiting
Poorly controlled Abdominal migraines
Adrenal insufficiency
Ipecac
Inadequate Input
MECHANICAL PROBLEMS
Cleft palette
Micognathia or Macroglosia
Tight labial frenulum
Nasal obstruction
Intestinal Obstruction (Volvulus,
Intusception, Hirschsprung’s,
Pyloric Stenosis)
Chronic constipation
Adenoidal hypertrophy
Dental lesions
Inadequate Input
SUCKING OR SWALLOW DYSFUNCTION
Neonatal Abstinence Syndrome
CNS pathology (stroke, tumor, hydrocephalus)
Genetics Syndromes (Trisomy)
Cardiopulmonary Disease
Neuromuscular weakness/tone
Cerebral Palsy
Anorexia of chromic infection, immune
deficiency, lead
Behavioral (apathy or rumination)
Causes of Failure to Thrive
Inadequate
Input
Increased
Utilization
Excessive
Output
Increased Utilization
CARDIAC DISEASE
Congenital or Acquired
SEPSIS
CHRONIC RESPIRATORY
INSUFFICIENCY
Bronchopulmonary dysplasia
Cystic fibrosis
RENAL DISEASE
partial posterior valves, severe reflux with UTI,
Renal Tubular Acidosis
HYPERTHYROIDISM
Increased Utilization
CHRONIC/RECURRENT
SYSTEMIC INFECTION
UTI, Tuberculosis, TORCH
HIV – degree of viremia
correlates with poor growth
MALIGNANCY
INFLAMMATORY BOWEL DISEASE
DIABETES MELLITUS
CHRONIC SYSTEMIC DISEASE
Juvenile Idiopathic Arthritis
Increased Utilization
Metabolic Disease
Inborn errors of metabolism
(normal infant that
deteriorates with lethargy,
poor feeding, convulsions,
vomiting)
Storage diseases
Hypercalcemia
Adrenal insufficiency
Causes of Failure to Thrive
Inadequate
Input
Increased
Utilization
Excessive
Output
Excessive Output
Biliary Atresia
Necrotizing Enterocolitis or Short Bowel Syndrome
Malabsorption
Lactose intolerance
Cardiac disease
Milk/food allergy or irritation
Cystic Fibrosis
Cystic fibrosis
Inflammatory bowel disease
Parasites
Celiac Disease
Infectious diarrhea
Renal losses
Fanconi Syndrome
Vitamin D resistance
Chronic renal insufficiency
Type I Diabetes Mellitus
Causes of Failure to Thrive
Inadequate
Input
Increased
Utilization
Excessive
Output
Isolated Linear Growth Deficiency
Familial Intrinsic Short
Stature
Chromosomal
Abnormality
Trisomy 13, 18, 21
Chromosome 22 del
Gonadal Dysgenesis
(45, X)
Skeletal Dysplasia
Endocrine Dysfunction
Pituitary Insufficiency
Hypothyroidism
GH deficiency/resistance
Younger children
Hypophosphatemic
Rickets
Older children
Hypercortisolism
Pseudohypoparathyroidism
Management Tips
•If clinically and socially stable, give yourself time and use
frequent observational follow up
•Even if clear organic cause evident do not forget about
psychosocial components – most organic causes have
mixed non-organic component
•Be clear with family about seriousness of child’s status
–insist they be seen
–“Ring the Bell” - get all hands on deck
Management Tips
•Look the grandmothers in the eye, get them on your side,
ask them what they think is wrong and give them jobs
•Ask all important members of the team for their assessment
and theories on treatment
•Normalize familial expectations
•Access parental dietary attitudes
–Unhealthy, sweet, hot/cold foods, fattening, food allergy
Management Tips
•Ask every time you meet with the family
–Diet
•“What are you feeding the child?”
–Caloric Intake
•“What exactly did your child eat in the last 24 hours?”
–Eating Environment
•“How are you feeding the child?”
–“What do you Think about your child’s feeding”
Expected Daily Weight Gain
grams/day
0 to 3 months
3 to 6 months
6 to 9 months
9 to 12 months
1 to 3 years
30
18
12
9
8
“Catch Up” weight gain is two to three times greater than
average for age
Calculating Calorie Need
Dietary Reference Intake (kcals/kg/day)
0 to 6 months
108
6 to 12 months
98
1 to 3 years
102
“Catch Up” calorie calculation 150% DRI
Alternative method
(DRI x median weight for length)/actual weight
Basal Intake Rate for Protein
2.2 grams/kg per day
Other Considerations
• Calculated calorie requirements are estimates. Severe
failure to thrive may require greater than 200kcal/kg
• Target calorie intake should be achieved over 5-7 days
• Malnutrition is usually associated with some degree of
anorexia
• High calorie feedings are hyperosmolar and may lead to
diarrhea or malabsorption
• Rapid refeeding may lead to hyperkalemia or
hypophosphatemia
Vitamin and Mineral Supplementation
•ZINC
–No reliable lab assessment
–Baseline addition
•IRON
–If Hemoglobin, Hematocrit or MCV labs indicate
further work up add to diet
Feeding Strategy
• Start with small quantities and advancing
as tolerated
• Pushing feeding further apart
• Assisted feeding to help caregiver
recognizing and responding to cues
of hunger and satiety, identify
active feeding
• Monitoring latch quality and persistence
of latch
Increasing Milk Caloric Content - INFANTS
•Breast Milk
–22 kcal/oz: add ½ scoop of formula to 4 ½ ounces
–24 kcal/oz: add 1 scoop of formula to 5 ounces
•Formula
–22 kcal/oz: add 2 ½ scoops of formula to 4 ½ ounces
of water
–24 kcal/oz: add 3 scoops of formula to 5 ounces of water
Increasing Milk Caloric Content - CHILDREN
•Increase calorie content of foods child likes to eat
–Adding rice cereal to pureed foods
–Replacing milk with high calorie substitutes
–Limiting low nutrition liquids
–Adding cheese, butter, sour cream, peanut butter to
fruits and vegetables
–Total energy and protein is more important than variety
Increasing Milk Caloric Content - CHILDREN
Increasing Caloric Density of Foods for Toddlers
Other Recipes
• 8 ounces of whole milk plus 2 Tbsp nonfat dry milk
powder = 24 calories/ounce
• 8 ounces of whole milk plus 3 Tbsp nonfat dry milk
powder = 28 calories/ounce
• 1 cup of whole milk, 1 package of instant breakfast and 1
cup ice cream = 430 calories
Adequate Response
• With adequate caloric and protein intake, “Catch Up”
growth is initiated in 2 to 14 days
• 4-9 months of accelerated growth must be maintained to
restore a child’s weight to height
• “Catch Up” height may lag behind weight by several
months
Medical Appetite Stimulation
Cyprohepatidine has no proven
long-term benefit
Lemons PK, Dodge NN. Persistent failure-to-thrive: a case study. J Pediatr
Health Care 1998; 12: 27.
Indications for Hospitalization
•Severe malnutrition
•Significant dehydration
•Serious medical problems
•Psychosocial risk to child
•Failure to respond to outpatient
management
•Precise documentation of caloric intake
•Extreme parental impairment or anxiety
•Severely disrupted parent-child axis
•Family issues make outpatient therapy impractical
Supplement Oral Feedings
•Severe malnutrition that is not
achieving adequate catch up in 4 to 6
weeks consider nasogastric feedings
•Discontinue when consistent weight
gain has been shown for 4 to 6
months
•If weight gain remains inadequate
after 3 to 4 months of nasogastric
feeds gastrostomy tube may be
appropriate
Frequent Follow Up
•Weekly follow up should continue until solid
baseline growth is demonstrated
•Use ancilary team members for observation
–Home health nurse
–WIC
–Dietitian
Refeeding Syndrome
•Sweatiness
•Hyperthermia
•Hepatomegaly – increased glycogen
deposition
•Widening of the cranial sutures- brain
growth faster than the skull
•Increased periods of sleep
•Fidgetiness or hyperactivity
Refeeding Syndrome
•Follow Potassium and Phosphorus
in the acute period of
reinstating nutrition
•Initial intracellular ion shifts my
cause
–Hypokalemia
–Hypophosphotemia
•Can produce serious arrhythmias
and muscle weakness
Can laboratory studies help diagnosis and management?
Can laboratory studies help diagnosis and management?
Not Usually
Sills et al (1978)
2607 laboratory tests were undertaken for the entire study group of 185 children hospitalized for failure
to thrive.
Only 36 (1.4%) of tests were of positive diagnostic significance. All of them were in the 34 patients
whose diagnosis was strongly suggested by history and examination.
Homer et al (1981)
82 children hospitalized for failure to thrive. History and examination was most sensitive indicator of
organic disease.
Berwick et al (1982)
122 infants hospitalized for failure to thrive.
Only 0.8% of tests were of positive diagnostic significance and 3.8% contributed to management. GI
related labs were most helpful but indication for labs usually appearant in history and examination.
How can laboratory studies help?
•Infection or chronic inflammation
•Electrolyte irregularity and monitor for refeeding impact
•Iron deficiency
•Vitamin deficiency(B12 or folate)
•Nutritional status (albumin and prealbumin)
•Fat soluble vitamins (ADEK)
•Evaluate signs of specific disease
–Cystic Fibrosis
–Metabolic Disease
How can laboratory studies help?
ELECTROLYTE IRREGULARITY AND MONITOR
REFEEDING IMPACT
Hypernatremic hypovolemia
Poor fluid volume from feeding
Hyponatremic
Unmanageble free water volume
RTA
Hyperaldosteronism
Hypomagnesium
Stool loses
Hypokalemia/Hypophosphatemia
How can laboratory studies help?
IRON DEFICIENCY
Most common nutritional deficiency in children
Labs
Mean Corpuscular Volume
Serum Iron
Plasma Ferritin
sensitive but also an acute phase reactant
Total Iron Binding Capacity,
Transferrin
Ususally associated with hypochromic, microcytic
morphology
How can laboratory studies help?
WATER SOLUBLE VITAMIN DEFICIENCY
Macrocytic Anemia
Serum B12 and Folate levels can be directly
measured
FAT SOLUBLE VITAMIN DEFICIENCY
Vitamin A, E and 25-hydroxyvitamin D can be
measured
Prothrombin Time is a good proxy measure of
Vitamin K
How can laboratory studies help?
EVALUATING NUTRITIONAL STATUS
Prealbumin
Synthesized in liver
Half-life 2 days
Exquisitely sensitive to adequate levels of protein
and energy intake
Low levels in children <13, neonates <4
Albumin
Synthesized in liver
Half-life 14-20 days so reflect last three weeks of
nutrition
Be careful with large protein losses from
circulation
Ascites, Renal disease, GI losses
How can laboratory studies help?
Cystic Fibrosis
Stool for fecal fat or trypsinogen
Other causes of malabsorption
Stool for reducing substances (carbohydrate
enzyme deficiencies)
Celiac Disease
Antibody Screening (Celiac Panel)
Endocrine Dysfunction
Growth hormone, IGF1, IGFBP3, TSH, free T4
Rule out if height above 50th percentile
How can laboratory studies help?
ZINC
Serum Zinc level have a high degree of
variation through the day
Assume Zinc deficiency in
malnutrition/growth failure
Long Term Considerations
Systematic review of cohort studies shows
Decreased IQ of questionable clinical
significance
Height and weight seem to be lower
percentiles
Psychomotor and educational
outcomes seem to be lower than
population norms
Red Flags for Medical Child
Abuse in Growth Deficiency
•
•
Child with no serious congenital anomaly or
confirmed genetic disorder
Greater than 5 organ symptoms involvement
Multiple presentations to previous institutions for
evaluation
Long and convoluted history with multiple
identifying features as treatment adherence
failure leads to next subspecialty evaluation
Refusing feeding team evaluation, home evaluation
or changing/adding formula/supplement
without medical consult
History of maternal pregnancy complications
•
Three of more parental-reported allergies
•
•
•
•
References
•Berwick DM et al. Failure to Thrive: Diagnostic Yield of Hospitalization. Archives of Disease in
Childhood. 1982; 57: 347-351.
•Bithoney WG, Dubowitz H, Egan H. Failure to thrive/growth deficiency. Pediatric Rev 1192; 13: 453.
•Ellerstein NS, Ostrov BE. Growth patterns in children hospitalized because of caloric-deprivation
failure to thrive. Am J Dis Child 1985; 139: 164.
•Frank DA. Failure to thrive. In: The Zuckerman Parker Handbook of Developmental and Behavioral
Pediatrics for Primary Care, 3rd ed, Augustyn M, Zuckerman B, Caronna EB (Eds), Lippincott Williams &
Wilkins, Philadelphia 2011. p.204.
•Frank D, Silva M, Needlman R. Failure to thrive: Mystery, myth and method. Contemp Pediatr 1993;
10: 114.
•Frank DA, Zeisel SH. Failure to thrive. Pediatr Clin North Am 1988; 35: 1187.
•National Research Council, Food and Nutrition Board. Recommended Daily Allowances. National
Academy of Sciences, 10th ed, National Academy Press, Washington, DC 1989.
•Goldbloom RB. Growth failure in infancy. Pediatr Rev 1987; 9: 57.
•Grey V, Landis L, Pall H, Drury D. Monitoring of 25-OH vitamin D levels in children with Cystic
Fibrosis. J Pediatr Gastroenterol Nutr 2000; 30: 314.
•Haynes CF, Cutler C, Gray J, Kempe RS. Hospitalized cases of nonorganic failure to thrive: the scope of
the problem and the short-term lay health visitor intervention. Child Abuse Negl 1984; 8: 229.
References
•Homer C. et al. Categorization of Etiology of Failure to Thrive. American Journal of the Diseases of
Children. Sept 1981; 135: 848-851.
•Ingenbleek Y, Young V. Transthyretin (prealbumin) in health and disease: nutritional implications.
Annu Rev Nutr 1994; 14: 495.
•Jafee AC. Failure to Thrive: Current Clinical Concepts. Pediatrics in Review 2011; 32: 100.
•Lemons PK, Dodge NN. Persistent failure-to-thrive: a case study. J Pediatr Health Care 1998; 12: 27.
•Mash C, Frazier T, Nowacki S, Worley S, Goldfarb J. Development of Risk-Stratification Tool for
Medical Child Abuse in failure to Thrive. Pediatrics 2011; 128; e1467.
•Maggiono A, Lifshitz F. Nutritional management of failure to thrive. Pediatr Clin North Am 1995; 42:
791.
•MacLean WC Jr, Lopez de Romana G, Massa E, Graham GC. Nutritional management of chronic
diarrhea and malnutrition: primary reliance on oral feeding. J Pediatr 1980; 97:316.
•Measurement of visceral protien status in assessing protein and energy malnutrition: standard of care.
Prealbumin in Nutritional Care Consensus Group. Nutritional Care Consensus Group. Nutrition 1995;
11:169.
•Rudolf M, Logan S. What is the long term outcome for children who fail to thrive? A systematic review.
Arch Dis Child 2005; 90: 925-931.
•Schmitt BD, Mauro RD. Nonorganic failure to thrive: an outpatient approach. Child Abuse Negl 1989;
13: 235.
References
•Seres DS. Surrogate nutritional markers, malnutrition and adequacy of nutrition suppot. Nutr Clin
Pract 2005; 20: 308.
•Sills RH. Failure to Thrive. The Role of Clinical and Laboratory Evaluation. American Journal of
Diseases of Children. Oct 1978; 132: 967-969.
•Smith DW, Truog W, Rogers JE, et al. Shifting linear growth during infancy: illustration of genetic
factors in growth from fetal life through infancy. J Pediatr. 1976;89:225-230
•Swartz I. Failure to Thrive: An Old Nemesis in the New Millenium. Pediatrics in Review 2000; 21: 257.
•Tougas L, et al. Dietary Manual, Department of Nutrition. Boston, MA: Children’s Hospital; 1991
•Walravens PA, Hambridge KM, Koepfer DM. Zinc supplementation in infants with a nutritional
pattern of failure to thrive: a double-blind, controlled study. Pediatrics 1989; 83: 532.
•Wright CM. Identification and management of failure to thrive: a community perspective. Arch Dis
Child 2000; 82: 5.
•Zenel JA Jr. Failure to thrive: a general pediatrician’s perspective. Pediatr Rev 1997; 18: 371.