Failure to Thrive
Premi Suresh, MD, FAAP
Learning Objectives
The participant will be able to…
• Review use of growth charts.
• Know how failure to thrive is identified.
• Be familiar with the three broad categories of
causes of Failure to Thrive (FTT).
• List ways in which FTT could result from abuse
and neglect.
• Learn strategies for management of children
with FTT.
Background
• Failure to Thrive (FTT) is a common problem
in pediatric populations
• Accounts for 1-5% of referrals to children’s
hospitals/tertiary care centers
• May be under diagnosed
• 20-50% may not be picked up by physician
Background
• In low-income countries, poverty is the most
common cause of Failure to Thrive; however,
medical providers, social services and law
enforcement must learn about the entire
family to see if this child – for any reason –
was not given food that was given to others in
the family.
GROWTH
CHARTS
Growth Charts
• U.S. Centers for Disease Control (CDC)
• Growth reference
• How children grow in the U.S.
• World Health Organization (WHO)
• Growth standard
• How children should grow in ideal conditions
• Recommended for use in children under 2
CDC or WHO?
• WHO growth chart may be better for children under
2 years old
• WHO more appropriate for exclusively breastfed
infant
• WHO may take into account cultural differences
• Still no consensus among providers
CDC chart
WHO Chart
FAILURE TO
THRIVE
Failure to Thrive
• Not a diagnosis - a description
• Inadequate nutrition to sustain normal growth and
development
• Significantly prolonged cessation of appropriate
weight gain compared with recognized norms for
age/gender after having achieved stable pattern
Criteria
• Weight curve crossing 2 major percentile
lines on growth chart after achieving stable
pattern
• Weight for age or weight for height more
than 2 standard deviations below mean for
gender/age
Weight
for
Height
Thomas
Midparental height
Boys: Father’s ht (in) + Mother’s ht (in)+5
2
Girls:
Father’s ht (in) + Mother’s ht (in) -5
2
Organic vs. Non-Organic
• Not a helpful distinction
• Both overlap
• Too simplistic
• Malnutrition causes growth failure
Causes of FTT
• Inadequate calories
• Inability to utilize calories
• Increased caloric needs
More than one of these causes can overlap!!
Normal Growth
Food
(calories)
Waste
Metabolism
Growth
Inadequate Calories
• Lack of knowledge
• Behavior
• Psychosocial
• Anatomic
Inadequate Calories
Lack of knowledge
Behavior issues
• Diet (low calorie,
excess juice, fads)
• Grazing
• Formula mixing
• Behavior problems
• Oral aversion
• Food phobia
Feeding Infants
• Breast milk or formula in first year of life
• No water needed in first 4-6 months
• Offer water in sippy cup
• Solids introduced at 4-6 months
• Juice not necessary!
• Should not exceed 4-6 ounces/day
• Transition to WHOLE milk at 1 yr of age
Growth in infancy
AGE
0-3
mos
3-6
mos
6-9
mos
9-12
mos
Weight
gain/day
(grams)
Weight
gain/mo
Growth in
length
(cm/mo)
Growth in
Head Circ
(cm/mo)
RDA
(kcal/kg/day)
30
2 lb
3.5
2.0
115
20
1.25 lb
2.0
1.0
110
15
1lb
1.5
0.5
100
12
13 oz
1.2
0.5
100
Caloric intake
• Breastmilk and Standard
Infant formula have 20
calories per oz
• Formula should be mixed 1
scoop to 2 oz water
• There are special formulas
with higher calories per oz
Toddlers
• Growth less rapid
• Can become picky
• Food “jags”
• Bottle should be discontinued
• Self feeding encouraged
• Avoid battles over food
Stop Grazing
• Offer 3 meals and 3 snacks per day
• Separate meals and snacks by 2-2.5 hours
• Only water between meals and snacks
• Meals and snacks should be offered at a table or
highchair and should last 20-25 minutes
• Solid foods should be offered before liquids
Inadequate Calories
Psychosocial
• Poverty/financial
• Formula mixing
• Abuse/neglect/IPV
• Parental mental health issues
• Parental eating disorders
Inadequate Calories
Anatomic
•Congenital anomalies
•Oromotor dysfunction
•Dental caries
•Gastroesophageal reflux
•Obstruction (i.e. pyloric stenosis)
Malabsorption
• Milk protein allergy
• Cystic fibrosis
• Pancreatic insufficiency
• Biliary atresia
• Short gut or necrotizing
enterocolitis
• Inflammatory bowel
disease
• Chronic diarrhea
• Disaccharidase deficiency
Inability
to Utilize
Calories
Improper utilization
• Inborn errors of
metabolism
• Storage disorders
• Growth hormone
deficiency
Increased Caloric Needs
• Prematurity
• Cancer
• Recurrent infection
• Kidney problems
• Renal tubular
acidosis, chronic renal
failure
• Cardiac disorders
• Congenital heart
disease, heart failure
• Pulmonary disorders
• Chronic lung disease,
poorly controlled
asthma
• Chronic liver disease
• Obstructive sleep apnea
• Chronic infection (HIV,
Tuberculosis)
Case Scenario
• Pt is a 2 yr 5 mo male brought to the
Hospital after being found unresponsive at
home. Doctors found the patient’s abdomen
was abnormally large, his legs were
extremely swollen and face and arms
appeared malnourished and gaunt. Doctors
report that patient has been found to have a
large abdominal tumor. Per mother’s report
patient has been “unwell” for several
months.
Findings
• Tumor: Metastatic Wilms (weighed 5 kg)
• Albumin <1
• Prealbumin 9 (nl 19-38)
• 3>5.4<53
• Head CT- brain atrophy
• Bony demineralization
Is this patient failing to thrive?
Causes of FTT
• Inadequate calories
• Inability to utilize calories
• Increased caloric needs
More than one of these causes can overlap!!
CHILD ABUSE
CAUSES OF
FTT
Child abuse causing FTT
• Neglect
• Pediatric Condition Falsification
• Other- effects of physical abuse, sexual abuse
Case Scenario
Patient is a 2 month old male. Mother took him to the
primary doctor for immunizations. Doctor became
concerned because the baby was very small and
considered to be failure to thrive. Baby’s birth weight
was 6 lbs, 6oz ( 3.3 Kg). At 1 month of age baby
weighed 7 lbs, 6 oz. At today’s 2 month visit, baby
weighed 7 lbs 5 oz. Mother told doctors that she gives
the baby 32 oz of formula per day which the doctors
said was an appropriate amount. Nurses report that
mother is not engaged in the child’s care and sleeps
most of the time. Nursing staff had to wake mother to
participate in diaper changes and feedings.
Child Abuse Causing FTT
• Neglect
•
•
•
•
•
•
Food withholding
Caregiver mental health issues
Caregiver substance abuse
Poor attachment
Domestic violence
Lack of follow through/medical neglect
Case Scenario
Case Scenario
Case Scenario
Case Scenario
Patient is a 12 month old female with failure to thrive.
Hospital physicians are concerned because child appears to
be normal, eat well and gain weight while in the hospital.
However, child’s primary physician is worried that the child
has an underlying medical condition. She frequently has
diarrhea and has days where she vomits with every meal.
The child has had numerous medical lab tests and imaging
studies that have not determined what is causing her
vomiting and diarrhea. Mother brings the child to all
appointments and seems very appropriate and engaged in
child’s care.
Child Abuse Causing FTT
• Fabricated or Induced Illness (Medical Child Abuse or
Pediatric Condition Falsification
• Induced FTT
• Giving the child laxatives, ipecac, etc
• Fabricated symptoms
• Reporting symptoms that child not experiencing
• Leads to further workup, tests
Child Abuse Causing FTT
Pediatric condition falsification (PCF)
• Caregivers typically present well
• May be extremely attentive
• “Model” caregivers
• Will be opposite of caregivers who are neglecting the
child
Child Abuse Causing FTT
• Physical/Sexual abuse
• Could cause behavioral symptoms that lead to
failure to thrive
• Food refusal
• Vomiting
• Can co-exist with neglect
Evaluation & Management
• History
• Physical exam
• Laboratory testing
• Treatment
History
• Prenatal/Birth
• Development
• Medical history
• Family history
• Surgical history
• Social history
• Medications
• Diet history
• Allergies
• Three day food diary
• Symptoms
Physical Exam
• Weight, height, head circumference
• Same scale best
• Standing height after 2 years of age
• Complete physical exam
• Observe parent-child interaction
• Observe feeding
• Signs of neglect
• Hygiene, teeth, diaper area
Laboratory Studies
• Focused lab evaluation
• Common labs include:
•
•
•
•
•
Complete blood count
Electrolytes
Urinalysis
Thyroid studies
Sweat test (cystic fibrosis)
• Majority of time, labs unhelpful
Treatment: Aimed at
Cause of FTT
• Dietary changes
• Increase calories
• Behavioral changes
• Scheduled, structured mealtimes
• Home visitation
• Document weight, check in with family, observe
home dynamics
• Hospitalization
• Severe cases, suspected abuse, failure of outpatient
treatment
Multidisciplinary Teams
• Best way to address FTT
• Medical Provider
• Dietician
• Social Worker
• Visiting nurse
• Occupational therapy
• Developmental specialist
Outcomes
• Depends on case
• Prognosis on growth typically good; however 2560% may remain small
• Cognitive deficits, learning disability, behavioral
problems seen in follow up
• Hard to tease out affects of FTT because of comorbidities
References
•
Kleinman R, Pediatric Nutrition Handbook 6th edition.
American Academy of Pediatrics; 2009.
•
Reece R, Christian C, eds. Child Abuse, Medical Diagnosis
and Management. 3rd edition. American Academy of
Pediatrics; 2009.
•
Block, BW, Krebs, NF, et al. Failure to Thrive as a
Manifestation of Child Neglect. Pediatrics 2005; 116:12341237.
•
Krugman, SD, Dubowitz, H. Failure to Thrive. Amer Fam
Phys 2003; 68(5): 879-884
•
Bools,C. Fabricated or Induced Illness in a Child by a
Carer: A Reader. Radcliffe Publishing, Oxford 2007