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Failure to Thrive

- Underlying medical disease - Dysmorphic features - Mental status (alert, responsive to stimuli) - Any signs of physical abuse and/or neglect

- Tests often considered in initial evaluation: - CBC, ESR - Electrolytes, BUN/creatinine, liver function tests - Urinalysis and urine culture - Lead level

- Prospective 3-day food diary for accurate record of caloric intake should be obtained. - Home visit by a clinician to observe infant feeding, interaction of caretakers, and home environment (3) - Observe breastfeeding and/or formula preparation to ensure adequacy and offer instruction. - Additional indicated evaluations may be performed by dietitians, occupational, physical and speech therapists, social workers, developmental specialists, psychiatrists, psychologists, visiting nurses, lactation consultants, and/or child protection services. - Can consider - Skeletal survey if suspicion of physical abuse - Bone age if possible endocrine disorder - Swallowing studies, small bowel follow-through if possible oromotor dysfunction, GERD, structural abnormalities - Brain imaging if microcephalic and/or neurologic findings on examination

- Try various strategies to increase caloric intake, such as the following: - Optimize breastfeeding support, consider supplementation. - Higher calorie formulas - Addition of rice cereal or fats to current foods - Limit intake of milk to 24 to 32 oz/day. - Avoid juice and soda. - Vitamin and/or nutritional supplements - Assist with social and family problems (WIC, food stamps, and other transitional assistance).

- Toddler - Three meals plus two nutritional snacks, 16 to 32 oz of milk/day; avoid juice and soda, and feed in a social environment. - Do not restrict fat and cholesterol in children <2 years.

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  • Children with genetic syndromes, intrauterine growth restriction (IUGR), or prematurity follow different growth curves.
  • 25% of children will decrease their weight or height crossing ≥2 major percentile lines in the first 2 years of life. These children are failing to reach their genetic potential or demonstrating constitutional growth delay (slow growth with a bone age < chronologic age). After shifting down, these infants grow at a normal rate along their new percentile and do not have FTT.

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EPIDEMIOLOGY

Incidence

  • Predominant age: 6 to 12 months; 80% <18 months
  • Predominant sex: male = female

Prevalence

  • As many as 10% of children seen in primary care have signs of growth failure.
  • 1-5% of pediatric inpatient admissions are for FTT.
  • Occurs more frequently in children living in poverty (1)

ETIOLOGY AND PATHOPHYSIOLOGY

  • Mismatch between caloric intake and caloric expenditure
  • Often grouped into four major categories:Inadequate caloric intake (most frequent)Inadequate caloric absorptionExcessive caloric expenditureDefective utilization
  • Traditionally, FTT was classified as organic or nonorganic, but most cases are multifactorial.
  • FTT often begins with a specific event and may lead to persistent difficulties.
  • Causes of FTT can be grouped by pathophysiology (including examples):Inadequate intake: breastfeeding difficulty, incorrect formula preparation, poor transition to food (6 to 12 months), poor feeding habits (e.g., excessive juice, restrictive diets), mechanical problems (e.g., oromotor dysfunction, congenital anomalies, GERD, CNS or PNS anomalies), oral aversion, poverty, neglect, poor parent-child interactionInadequate absorption: necrotizing enterocolitis, short gut syndrome, biliary atresia, liver disease, cystic fibrosis, celiac disease, milk protein allergy, vitamin/mineral deficiencyIncreased expenditure: hyperthyroidism, congenital/chronic cardiopulmonary disease, HIV, immunodeficiencies, malignancy, renal diseaseDefective utilization: metabolic disorders, congenital infections (TORCH: toxoplasmosis, other agents, rubella, cytomegalovirus, herpes simplex)

Genetics

Multiple genetic disorders can cause FTT. пїЅ

RISK FACTORS

  • Psychosocial risksPoverty, parent(s) with mental health disorder or cognitive impairment, poor parenting skills or hypervigilant parents, families with unique health/nutritional beliefs, physical or emotional abuse, substance abuse, and social isolation
  • Medical risksIntrauterine exposures, history of IUGR (symmetric or asymmetric), congenital abnormalities, oromotor dysfunction, premature or sick newborn, infant with physical deformity, acute or chronic medical conditions, developmental delay, lead poisoning, anemia

Pregnancy Considerations

FTT is linked to intrauterine exposures, IUGR, and prematurity.

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GENERAL PREVENTION

  • Educate parents on normal feeding and parenting skills.
  • Access to supplemental feeding programs (women, infants, and children [WIC])

DIAGNOSIS

HISTORY

  • Prenatal and developmental history
  • Past medical history: acute/chronic disease affecting caloric intake, digestion, absorption, or causing increased energy need or defective utilization
  • Medication history, including complementary and alternative medications
  • Family history: stature of parents and growth trajectories of siblings, chronic diseases, genetic disorders, developmental delay
  • Diet history from birth: breastfeeding or formula feeding; timing and introduction of solids; who feeds the child, when, and how often; placement of child during feeds; amounts consumed/caloric intake; beverages consumed; snacking; vomiting or stooling associated with feeds; oral aversions or unusual behaviors during feeding
  • Social history: family composition, socioeconomic status, child-rearing beliefs, stressors, parental depression, parental substance abuse, caretaker personal history of abuse/neglect
  • Review of systems: anorexia, activity level, mental status, fevers, dysphagia, vomiting, gastroesophageal reflux, stooling pattern/consistency, dysuria, urinary frequency

PHYSICAL EXAM

  • A combination of anthropometric criteria, rather than one criterion should be used (1)[C].
  • Accurate measurement of height, weight, and head circumference on National Center for Health Statistics (NCHS) growth charts (www.cdc.gov/growthcharts) (2).
  • The World Health Organization (WHO) growth charts may be more appropriate for breastfed infants (www.who.int/childgrowth/standards/en/).
  • Growth charts exist for many other syndromes/conditions such as Down syndrome, Turner syndrome, and the premature infant.
  • Exam should assess for the following:Signs of dehydration or severe malnutrition are as follows:Severity of malnutrition estimated via Gomez classification: Compare current weight for age with expected weight for age (50th percentile): severe, <60% of expected; moderate, 61-75%; mild, 76-90%.Underlying medical diseaseDysmorphic featuresMental status (alert, responsive to stimuli)Any signs of physical abuse and/or neglect
  • Observe interaction with caregivers and feeding techniques, specifically bonding and social/psychological cues.

DIFFERENTIAL DIAGNOSIS

Differentiate based on growth patterns пїЅ

  • FTT classically presents as low weight for age, normal linear growth, normocephalic or low weight for age, followed by decreased linear growth or low weight for age, leading to decreased linear growth and decreased head circumference (without neurologic signs).In this situation, consider differential diagnosis as outlined in "Etiology and Pathophysiology."пїЅ
  • If low linear growth with normal weight for length or low linear growth and proportionately low weight and decreased head circumference:Consider genetic potential (constitutional short stature or growth delay), genetic syndromes, teratogens, endocrine disorders
  • If microcephaly with prominent neurologic signs, with poor growth secondary to presumed neurologic disorder:Consider TORCH infections, genetic syndromes, teratogens, brain injury (i.e., hypoxic/ischemic)

DIAGNOSTIC TESTS & INTERPRETATION

  • Labs useful only in ~1% of cases and are generally not recommended (1)[C].
  • A period of addressing nutritional causes is preferable prior to extensive labs and other workup.

Initial Tests (lab, imaging)

Labs should be ordered based on history and physical exam findings and the age of the patient. пїЅ

  • Tests often considered in initial evaluation:CBC, ESRElectrolytes, BUN/creatinine, liver function testsUrinalysis and urine cultureLead level
  • Other tests as dictated by the history and exam:TSH, amylase/lipase, serum zinc level, iron studies, karyotype, genetic testing, sweat chloride test, stool for ova and parasite or fat/reducing substances, guaiac, О±-1-antitrypsin and elastase, radioallergosorbent test for IgE food allergies, tissue transglutaminase and total IgA (celiac sprue), P-ANCA and anti-Saccharomyces cerevisiae antibodies (for inflammatory bowel disease [IBD]), TB test, HIV, ELISA, hepatitis A and B, other infections

Follow-Up Tests & Special Considerations

  • Prospective 3-day food diary for accurate record of caloric intake should be obtained.
  • Home visit by a clinician to observe infant feeding, interaction of caretakers, and home environment (3)
  • Observe breastfeeding and/or formula preparation to ensure adequacy and offer instruction.
  • Additional indicated evaluations may be performed by dietitians, occupational, physical and speech therapists, social workers, developmental specialists, psychiatrists, psychologists, visiting nurses, lactation consultants, and/or child protection services.
  • Can considerSkeletal survey if suspicion of physical abuseBone age if possible endocrine disorderSwallowing studies, small bowel follow-through if possible oromotor dysfunction, GERD, structural abnormalitiesBrain imaging if microcephalic and/or neurologic findings on examination

TREATMENT

GENERAL MEASURES

  • Treat underlying conditions.
  • Caregiver and infant interaction should be evaluated in infants and children with FTT.
  • Age appropriate nutritional counseling should be provided (1)[C].The goal is to improve nutrition to allow catch-up growth (weight gain 2 to 3 times > average for age).
  • Calculate energy needs based on recommended energy intake for age, increased by 50%.Recommended energy intake (use expected, not actual weight, to calculate needs)0 to 1 month: 120 kcal/kg/day1 to 2 months: 115 kcal/kg/day2 to 3 months: 105 kcal/kg/day3 to 6 months: 95 kcal/kg/day6 months to 3 years: 90 kcal/kg/day (4)[C]
  • Alternatively, may calculate caloric requirements for infants to achieve catch-up growthkcal/kg/day required = RDA for age (kcal/kg) пїЅ ideal weight for height/actual weight, where ideal weight for height is the median weight for the patient's height
  • Try various strategies to increase caloric intake, such as the following:Optimize breastfeeding support, consider supplementation.Higher calorie formulasAddition of rice cereal or fats to current foodsLimit intake of milk to 24 to 32 oz/day.Avoid juice and soda.Vitamin and/or nutritional supplementsAssist with social and family problems (WIC, food stamps, and other transitional assistance).
  • Rapid high-calorie intake can cause diarrhea, malabsorption, hypokalemia, and hypophosphatemia. Therefore, increasing formulas more than 24 kcal/oz is not recommended.
  • The target energy intake should be slowly increased to goal over 5 to 7 days.
  • Catch-up growth should be seen in 2 to 7 days.
  • Accelerated growth should be continued for 4 to 9 months to restore weight and height.

MEDICATION

Use only for identified underlying conditions. пїЅ

ISSUES FOR REFERRAL

  • Refer as indicated for underlying conditions.
  • Multidisciplinary care is beneficial (1)[B]. Specialized multidisciplinary clinics may be of benefit for children with complicated situations, failure to respond to initial treatment, or when the PCP does not have access to specialized services such as nutrition, psychology, PT/OT, and speech therapy (2).

ADDITIONAL THERAPIES

In severe cases, nasogastric tube feedings or gastrostomy may be considered. пїЅ

INPATIENT CONSIDERATIONS

Most cases of FTT can be managed as outpatients. пїЅ

Admission Criteria/Initial Stabilization

Hospitalization should be considered if (1)[C]: пїЅ

  • Outpatient management fails.
  • There is evidence of severe dehydration or malnutrition.
  • There are signs of abuse or neglect.
  • There are concerns that the psychosocial situation presents harm to child.
  • During catch-up growth, some children will develop nutritional recovery syndrome:Symptoms include sweating, increased body temperature, hepatomegaly (increased glycogen deposits), widening of cranial sutures (brain growth > bone growth), increased periods of sleep, fidgetiness, and mild hyperactivity.
  • There may also be an initial period of malabsorption with resultant diarrhea.

Discharge Criteria

Catch-up growth should be seen in 2 to 7 days. If this is not seen, reevaluation of causes is needed. пїЅ

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

  • If specific disease is identified, follow-up as indicated.
  • Close long-term follow-up with frequent visits is important to create and maintain a healthy, supportive environment (3).
  • Children with history of FTT are at increased risk of recurrent FTT, and growth should be monitored closely (1,4).
  • If the family fails to comply, child protection authorities must be notified.

DIET

Nutritional requirements for a "normal"пїЅ child: пїЅ

  • Infant120 kcal/kg/day, decreased to 95 kcal/kg/day at 6 months; if breastfed, ensure appropriate frequency and duration of feeding.Between 6 and 12 months, continue breast milk and/or formula, but pureed foods should be consumed several times a day during this period.
  • ToddlerThree meals plus two nutritional snacks, 16 to 32 oz of milk/day; avoid juice and soda, and feed in a social environment.Do not restrict fat and cholesterol in children <2 years.
  • Rate of weight gain expected for age:0 to 3 months: 26 to 31 g/day3 to 6 months: 17 to 18 g/day6 to 9 months: 12 to 13 g/day9 to 12 months: 9 g/day1 to 3 years: 7 to 9 g/day

PATIENT EDUCATION

  • Counsel parents regarding the need to avoid "food battles,"пїЅ which worsen the problem.
  • Educate parents regarding infant social and physiologic cues, formula/food preparation, proper feeding techniques, and importance of relaxed and social mealtimes.
  • When environmental deprivation is identified, educating in a nonpunitive way is essential.
  • "Failure to thrive: What this means for your child,"пїЅ available from AAFP at: www.aafp.org/afp/2011/0401/p837.html
  • WIC provides grants to states for supplemental foods, health care referrals, and nutrition education for low-income pregnant, breastfeeding, and nonbreastfeeding postpartum women and to infants and children up to age 5 years at nutritional risk: www.fns.usda.gov/wic/

PROGNOSIS

  • Many children with FTT show adequate improvement in dietary intake with intervention.
  • Some studies looking at children with FTT have demonstrated an association with later problems with cognitive development, behavioral issues, and growth, but there is no consensus on these long-term outcomes or their clinical significance (1).
  • Children with FTT are at increased risk for future undernutrition, overnutrition, and eating disorders.

REFERENCES

11 Cole пїЅSZ, Lanham пїЅJS. Failure to thrive: an update. Am Fam Physician. 2011;83(7):829-834.22 Grissom пїЅM. Disorders of childhood growth and development: failure to thrive versus short stature. FP Essent. 2013;410:11-19.33 Shields пїЅB, Wacogne пїЅI, Wright пїЅCM. Weight faltering and failure to thrive in infancy and early childhood. BMJ. 2012;345:e5931.44 Krugman пїЅSD, Dubowitz пїЅH. Failure to thrive. Am Fam Physician. 2003;68(5):879-884.

ADDITIONAL READING

  • Atalay пїЅA, McCord пїЅM. Characteristics of failure to thrive in a referral population: implications for treatment. Clin Pediatr (Phila). 2012;51(3):219-225.
  • Jaffe пїЅAC. Failure to thrive: current clinical concepts. Pediatr Rev. 2011;32(3):100-107.
  • Kerzner пїЅB, Milano пїЅK, MacLean пїЅWCJr, et al. A practical approach to classifying and managing feeding difficulties. Pediatrics. 2015;135(2):344-353.

CODES

ICD10

  • R62.51 Failure to thrive (child)
  • P92.6 Failure to thrive in newborn

ICD9

  • 783.41 Failure to thrive
  • 779.34 Failure to thrive in newborn

SNOMED

  • 54840006 Failure to thrive (disorder)
  • 433476000 failure to thrive in infant (disorder)

CLINICAL PEARLS

  • FTT is a sign of inadequate nutrition.
  • Underlying medical and/or social issues are generally suggested by history and physical exam, and extensive laboratory or imaging tests are rarely needed.
  • A multidisciplinary team approach to diagnosis and treatment is critical to help children with FTT and their families.
  • Prompt diagnosis and intervention is important to decrease the risk of adverse effects.