Failure To Thrive


Article Author:
Ashley Smith


Article Editor:
Madhu Badireddy


Editors In Chief:
David Wood
Andrew Wilt
Hajira Basit


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
6/3/2019 5:00:27 PM

Introduction

Failure to thrive (FTT) is a common term used to describe lack of adequate weight gain in pediatric-aged patients. Accepted definitions include a weight for age less than the fifth percentile on standardized growth charts, a decrease in weight percentile of more than two major percentile lines on the growth chart, or less than the 80 percentile of median weight for height ratio weight/length ratio. [1]  Failure to thrive is important to recognize and treat because it can result in developmental delays and other long-term effects for the developing child.

Etiology

Failure to thrive is often multifactorial in etiology. One way to classify potential causes is to think about three big categories of why a patient is failing to gain weight adequately. The categories include decreased intake, increased output, and increased caloric demand. Also, causes can be described as either organic or inorganic.[2] There are multiple underlying pathologic conditions or organic causes that can lead to the three categories outlined above. For example, a patient with a swallowing abnormality may not be able to physically take in enough calories to gain weight. Conversely, a patient with chronic diarrhea may be losing more calories than he consumes. Lastly, a patient with congenital heart disease may have increased caloric demands and be unable to keep up. While there is a myriad of potential organic causes, inorganic causes are more common. Inorganic causes include some outside reasons for not getting enough calories. Examples might include improper mixing of infant formulas, feeding refusal, or parental neglect.[3][4][5][6]

Epidemiology

While failure to thrive can affect patients of all ages, it is most common in infants and younger children. There is no gender or race predisposition. Failure to thrive has been associated with lower socioeconomic status, lower parental education level, and with other increased psychosocial stressors in the home environment.

Pathophysiology

The pathophysiology of failure to thrive depends on the underlying etiology. However, at its base is a lack of necessary calories for adequate growth. This could be from not taking in enough calories, losing too many calories, or increased caloric demand. There are multiple formulas available for calculating caloric needs based on age and gender that can be helpful for catch-up growth once the underlying etiology is identified.

History and Physical

The history and physical exam are vital when assessing a patient with failure to thrive. Often, the patient may have no specific presenting symptoms but is then found to have inadequate growth when they present for a routine well visit. Other patients may have more obvious signs and symptoms associated with their underlying condition which have led to the failure to thrive. In the history, it is important to note a detailed feeding history including types of food, amount, and frequency. Feeding refusal, texture preferences, difficulty swallowing, or frequent emesis should be noted. If the infant is formula fed, identifying the formula mixing technique used can be helpful. Tachypnea, fatigue, or diuresis with feeds may also be important if present. In addition, documenting urine output, any unusual urine smells, and stool frequency and consistency are also helpful. Developmental milestones should be assessed and any delays documented. Past medical history may provide clues to an underlying organic etiology. Specifically, congenital abnormalities such as known congenital heart disease, esophageal abnormalities, intestinal abnormalities, endocrine disorders, and genetic disorders are often associated with failure to thrive. Family medical history including prenatal history can be pertinent, especially when considering potential underlying organic etiologies. The physical exam should note the rate of weight gain or loss from last visit as well as the current weight and height percentiles. Carefully assessing for any hints to an organic etiology such as an oral motor dysfunction, heart murmur, tachypnea, abnormal abdominal or genitourinary (GU) exam, or prominent skin lesions is essential. Often, the exam will be notable only for the poor weight gain and a thin appearing infant without providing any specific clues to the underlying cause.

Evaluation

Evaluation of failure to thrive should include confirmation of poor weight gain over time (depending on the severity of weight loss/clinical status at initial presentation). If possible, an observation of feeding, especially in younger infants can be very informative. If truly failure to thrive, an initial laboratory evaluation can be helpful to rule out common organic causes and guide the provider to more specific tests if needed. Initial labs should include a complete blood count (CBC) to assess for anemia, iron panel because the most common type of anemia in this age group is iron deficiency, and a metabolic panel to assess electrolyte and hydration status, liver, and kidney function. An erythrocyte sedimentation rate (ESR) can be useful to identify nonspecific underlying inflammation. Prealbumin can assess overall nutritional status and if low initially can be used to trend treatment response later on. Send screening thyroid function studies including thyroid-stimulating hormone (TSH) and Free T4. A normal newborn metabolic screen should be documented; if not, sending one can provide clues to less common organic causes of failure to thrive. A urinalysis is also important to assess kidney function. If there is a prominent history of abnormal stooling, stool studies including culture, guiac, and reducing substances may be helpful. Pending results of the first set of basic labs, more specific labs may be indicated such as a chloride sweat test, pancreatic function testing, or other metabolic-specific testing. While imaging is not routinely indicated initially, chest x-ray, ECG/echocardiogram, and endoscopy may be useful to determine certain conditions if there is a concern for an anatomic abnormality. [2]

Treatment / Management

Treatment for failure to thrive includes identifying the underlying etiology and addressing the caloric deficit. Often, patients are admitted to an inpatient setting to facilitate the workup, observe feeds and to ensure appropriate weight gain prior to discharge. However, depending on the clinical status of the patient this may not always be warranted. Whenever possible, enteral feeds should be provided. For patients with feeding refusal or inability to consume enough calories, nasogastric tubes (in the short-term) and gastrostomy tubes (long-term) are sometimes needed. Parenteral nutrition is a last resort. For patients with increased caloric demands, working with nutritionists to prescribe a high-calorie diet that is appropriate for the patient is essential. Establishing specific meal times and routines can help with toddlers who have difficulty feeding. Minimizing fruit juices and empty calories is also helpful. For patients with increased caloric losses, there are often disease-specific treatments to address this issue. An example would be pancreatic enzyme replacement in cystic fibrosis patients. Frequent follow-ups to confirm weight gain, once it is established, is essential. If needed, parental education and additional psychosocial support can be very helpful.[7][8][9][10]

Pearls and Other Issues

The importance of psychosocial factors such as low socioeconomic status, parental drug or alcohol abuse, postpartum depression, and parental education must be considered. Remember that most causes of failure to thrive (FTT) are inorganic. Addressing these psychosocial factors is often the key to restoring adequate weight gain for the patient. While an uncommon cause, parental neglect, and abuse must be a consideration.

Enhancing Healthcare Team Outcomes

FTT to thrive is best managed by a multidisciplinary team that includes nurses. There are many causes of FTT and thus clinicians need to obtain a thorough history. Often an exhaustive workup is required. Simply admitting the patient and administering parenteral nutrition is not recommended; enteral nutrition is always preferred. Until the cause of FTT is discovered, no treatment will work. A dietitian, mental health counselor, and a social worker should be involved in chronic cases of FTT; sometimes the cause is not organic but can even be a mental health problem or even child abuse.

The outlook of patients depends on the cause. In most cases, the recovery is slow and gradual and may be associated with mild to moderate neuropsychiatric deficits.[11][12]


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Failure To Thrive - Questions

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A 1-year-old child is brought in for a well child visit to a new caregiver. The child was born at 39 weeks gestation and delivery history is unremarkable. The growth chart shows the weight was initially at the 50th percentile and increased to the 75th percentile by 6 months. It dropped to the 25th percentile at 9 months and is at the 10th percentile now. Length has remained stable at the 50th percentile. What is the most likely explanation for these changes?



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A 1-year-old child is diagnosed with failure to thrive. The child has two older siblings that are healthy. The child is active and has had normal developmental milestones. She drinks 12 ounces of whole milk and 12 ounces of grape juice daily. She will not eat meat, so she mostly eats fruit and rice. Which of the following interventions is least appropriate?



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Which is not a risk factor for failure to thrive?



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A toddler with developmental issues is referred for a home evaluation. The child also has failure to thrive. The parents complain that the child refuses to eat at meals. Which of the following would be least helpful?



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A 2-year-old child is at the fifth percentile for weight. The parents state that the child refuses to eat. Which of the following would not be an appropriate recommendation?



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A 6-month-old male is brought by his mother for a routine visit. He is formula fed and recently started solid foods. His weight percentile at previous visits was the 50th percentile. Today, his weight is recorded at the 15th percentile. He has no known medical conditions and is developmentally appropriate for age. Which of the following is the most appropriate next step in his evaluation?



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An 18-month-old child with known failure to thrive presents to the outpatient clinic for a weight check. The patient was discharged from the hospital last week. During his hospitalization, the patient demonstrated that he was able to consume the recommended amount of daily calories by mouth, and he was gaining weight at the time of discharge. In clinic today, he is well appearing. However, he has lost 0.5 kg from his discharge weight. What is the most important next step in his management?



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A 2-month-old female is brought to the clinic by her mother for a routine visit. She is breast milk and formula fed. At her last visit, her weight was the 5th percentile for age. Today, she has gained minimal weight since the last visit, and her weight percentile is now less than the 1st percentile. Which of the following is most concerning for an organic etiology of her poor weight gain?



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A 9-month-old female is brought to the clinic by her mother for a routine visit. She is breastfed and also eats a variety of baby foods. The mother reports no constipation or diarrhea. She is developmentally appropriate and recently started crawling consistently and can also pull to a stand with support. The parents have no concerns today. At her last visit, her weight percentile was the 80th percentile. Today, her weight is at the 65th percentile for age. The remainder of her physical exam is normal. What is the next most appropriate step in her management?



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Failure To Thrive - References

References

Faltering growth., Dean E,, Nursing children and young people, 2017 Jun 12     [PubMed]
Failure to Thrive: A Practical Guide., Homan GJ,, American family physician, 2016 Aug 15     [PubMed]
Kim Y,Wang SE,Jiang YH, Epigenetic therapy of Prader-Willi syndrome. Translational research : the journal of laboratory and clinical medicine. 2019 Mar 5;     [PubMed]
Bazacliu C,Neu J, Necrotizing Enterocolitis: Long Term Complications. Current pediatric reviews. 2019 Mar 11;     [PubMed]
Agyemang A,Nowak-Wegrzyn A, Food Protein-Induced Enterocolitis Syndrome: a Comprehensive Review. Clinical reviews in allergy     [PubMed]
van Kalleveen MW,de Meij T,Plötz FB, [Coeliac disease in children: a changing clinical spectrum]. Nederlands tijdschrift voor geneeskunde. 2019 Mar 19;     [PubMed]
Warren J, An update on complementary feeding. Nursing children and young people. 2018 Nov 8;     [PubMed]
Mangili G,Garzoli E,Sadou Y, Feeding dysfunctions and failure to thrive in neonates with congenital heart diseases. La Pediatria medica e chirurgica : Medical and surgical pediatrics. 2018 May 23;     [PubMed]
Ross E,Munoz FM,Edem B,Nan C,Jehan F,Quinn J,Mallett Moore T,Sesay S,Spiegel H,Fortuna L,Kochhar S,Buttery J, Failure to thrive: Case definition     [PubMed]
Gonzalez-Viana E,Dworzynski K,Murphy MS,Peek R, Faltering growth in children: summary of NICE guidance. BMJ (Clinical research ed.). 2017 Sep 28;     [PubMed]
Malek AJ,Mrdutt MM,Scrushy MG,Mallet LH,Shaver CN,Sanders EC,Stagg HW,Perger L, Long-term growth outcomes in neonates diagnosed with necrotizing enterocolitis: a 20-year analysis. Journal of pediatric surgery. 2019 May;     [PubMed]
Viswanathan M,Fraser JG,Pan H,Morgenlander M,McKeeman JL,Forman-Hoffman VL,Hart LC,Zolotor AJ,Lohr KN,Patel S,Jonas DE, Primary Care Interventions to Prevent Child Maltreatment: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2018 Nov 27;     [PubMed]

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