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Failure to Thrive (Weight Faltering), Pediatric

Basics

Description

- Dietary - Breastfeeding difficulties - Diluted or inappropriately prepared formula - Food fads or restrictions

- Developmental/neurologic - Oral motor difficulties - Central nervous system abnormalities

- Social - Unavailability of food - Parent-child interaction disorders - Mental health or behavioral disorders affecting child's appetite - Mental health disorders affecting caregiver's parenting abilities - Disorganized meal times - Neglect (omitting feeds or creating environment not conducive to feeding)

- Medical - Adenotonsillar hypertrophy - Cleft lip and/or palate - Dental pain and decay - Congenital cardiac disease - Gastroesophageal reflux disease - Dysphagia

- Prenatal - Multiple miscarriages (suggesting a genetic disorder) - Maternal health and/or medical diagnoses - Tobacco, alcohol, or illicit substances - Other teratogens or toxins (prescribed medication, radiation exposure)

- Birth - Gestational age at delivery - Weight, length, and head circumference - Asphyxia, infection, other perinatal complications

- Medical - Newborn metabolic screening results - Medical diagnoses: reflux, cardiac disease, obstructive sleep apnea, respiratory infections, urinary tract infections, other chronic or recurrent conditions - Hospitalizations, surgeries, immunizations - Event(s) at time of significant loss or gain of weight

- Family - Weight, height of biologic parents and siblings - Parental history of childhood growth delay - Medical, mental, and developmental diagnoses of parents and siblings - Maternal postpartum depression - Caregiver(s) use of illicit substances

- Review of systems - Activity level compared to peers - Chronic rhinorrhea, congestion, cough - Mouth breathing, snoring, frequent awakenings from sleep - Difficulty or pain with sucking, chewing, or swallowing - Vomiting or excessive spitting up - Breathlessness, sweating, or tiring during feeds - Frequent, large, bloody, or oily stools - Constipation - Urinary frequency or dysuria - Polyuria, polydipsia, polyphagia - Eczema or urticaria exacerbated by select foods

- Psychosocial - Difficulty purchasing or preparing food - Distractions during feeds/meals - Perception of child's behavior during meals - Eating habits of siblings when at a similar age as infant/child with FTT - Individual and family stressors and strengths - Supplemental food and community resources - Travel to less developed countries

- Dietary - Frequency, duration of active suck - Frequency, type, preparation, quantity of typical formula feed - Feeding changes at night or on weekends - Age of weaning/shift in feeding practices - Foods consumed over typical 24 hours - Water, juices, sodas over typical 24 hours - Food allergies or intolerances - Feeding habits and techniques (bottle propping, grazing) - Eating habits outside the home (day care, school) - Vitamin, herbal, other supplements

- Subspecialty consultation - Minimize risk of refeeding syndrome - Genetic syndrome or disease suspected

Failure to thrive (FTT) or weight faltering describes a pattern of growth that is below established standards for age and gender. Anthropometric FTT is defined as any one of the following:

  • Weight (or weight for length/height) <2 standard deviations below mean
  • Weight deceleration of more than 2 major percentile lines after a previously established pattern
  • Weight <75% of median weight for chronologic age
  • Weight <80% of median weight for length
  • Weight for chronologic age <5th percentile
  • Body mass index for chronologic age <5th percentile
  • Length for chronologic age <5th percentile

Epidemiology

  • FTT often begins in the first 6 months of life but may not be diagnosed until after 1 year of age.
  • It is difficult to accurately determine FTT incidence or prevalence as there is neither consensus on the best definition of FTT nor concordance between definitions. Depending on definition selected, prevalence can range from 1% to 22% based on an analysis of infants from a Danish Birth Registry.

Risk Factors

No single risk factor uniformly predicts FTT.

  • Substantiated child abuse or neglect is 4 times more likely in FTT children compared to non-FTT children. However, maltreatment is a primary concern in only 4-5% of FTT cases.
  • Family poverty was traditionally believed to be an important risk for FTT. However, recent prospective studies of large populations seen in general pediatric clinics have either been equivocal or failed to show poverty to be an important risk factor.
  • Maternal mental health vulnerabilities, maternal education, and infant characteristics have also been equivocal.
  • Currently, there is consensus that FTT involves a multiplicity of overlapping dietary, developmental, social, and medical concerns.

General Prevention

Advice should be straightforward, practical, and tailored to specific needs.

  • Primary preventionAddresses proper formula and food preparation, feeding quantities and frequencies, community-based nutrition support programs, and mental health resources
  • Secondary preventionInvolves early identification by regular growth monitoring
  • Tertiary preventionRequires creation of an individualized treatment plan that addresses specific factors (dietary, developmental, social, and medical) adversely affecting a child's ability to meet caloric needsLong-term, coordinated multidisciplinary efforts involving home visiting nurses, dietitians, social workers, primary care providers, and medical subspecialists are critical to success.

Pathophysiology

Inadequate Caloric Intake

  • DietaryBreastfeeding difficultiesDiluted or inappropriately prepared formulaFood fads or restrictions
  • Developmental/neurologicOral motor difficultiesCentral nervous system abnormalities
  • SocialUnavailability of foodParent-child interaction disordersMental health or behavioral disorders affecting child's appetiteMental health disorders affecting caregiver's parenting abilitiesDisorganized meal timesNeglect (omitting feeds or creating environment not conducive to feeding)
  • MedicalAdenotonsillar hypertrophyCleft lip and/or palateDental pain and decayCongenital cardiac diseaseGastroesophageal reflux diseaseDysphagia

Inadequate Absorption or Utilization

  • Food allergies or intolerances
  • Inflammatory bowel disease
  • Gastrointestinal malformations
  • Pyloric stenosis
  • Hepatitis
  • Cystic fibrosis
  • Parasitic infections
  • Inborn errors of metabolism

Increased Caloric Expenditure

  • Hyperthyroidism
  • Chronic infections
  • Chronic immunodeficiencies
  • Malignancy
  • Pulmonary disease
  • Cardiac disease
  • Renal disease

Etiology

  • Historically, FTT was classified as organic (secondary to medical illness) or inorganic (secondary to psychosocial concerns). This categorization is obsolete. It places inordinate emphasis on organic conditions. In outpatient primary care settings, an identifiable organic disease likely contributes to FTT in <18% of children age 2 years or younger.
  • Children with FTT may eat less. An undemanding child temperament, low appetite, and disinterest in food may either cause or result in FTT.
  • FTT children also have significantly fewer positive mealtime interactions with caregivers. Family dysfunction, caregiver incompetence, lack of knowledge about child development, and caregiver mental health vulnerabilities can affect a caregiver-child feeding relationship.

Commonly Associated Conditions

Severe, chronic FTT may have significant adverse effects on cognition, attention, and behavior.

Diagnosis

History

Responses to questions about the following can help guide evaluation:

  • PrenatalMultiple miscarriages (suggesting a genetic disorder)Maternal health and/or medical diagnosesTobacco, alcohol, or illicit substancesOther teratogens or toxins (prescribed medication, radiation exposure)
  • BirthGestational age at deliveryWeight, length, and head circumferenceAsphyxia, infection, other perinatal complications
  • MedicalNewborn metabolic screening resultsMedical diagnoses: reflux, cardiac disease, obstructive sleep apnea, respiratory infections, urinary tract infections, other chronic or recurrent conditionsHospitalizations, surgeries, immunizationsEvent(s) at time of significant loss or gain of weight
  • DevelopmentalPersonal-social, language, fine and gross motor milestonesLoss of previously acquired milestones
  • FamilyWeight, height of biologic parents and siblingsParental history of childhood growth delayMedical, mental, and developmental diagnoses of parents and siblingsMaternal postpartum depressionCaregiver(s) use of illicit substances
  • Review of systemsActivity level compared to peersChronic rhinorrhea, congestion, coughMouth breathing, snoring, frequent awakenings from sleepDifficulty or pain with sucking, chewing, or swallowingVomiting or excessive spitting upBreathlessness, sweating, or tiring during feedsFrequent, large, bloody, or oily stoolsConstipationUrinary frequency or dysuriaPolyuria, polydipsia, polyphagiaEczema or urticaria exacerbated by select foods
  • PsychosocialDifficulty purchasing or preparing foodDistractions during feeds/mealsPerception of child's behavior during mealsEating habits of siblings when at a similar age as infant/child with FTTIndividual and family stressors and strengthsSupplemental food and community resourcesTravel to less developed countries
  • DietaryFrequency, duration of active suckFrequency, type, preparation, quantity of typical formula feedFeeding changes at night or on weekendsAge of weaning/shift in feeding practicesFoods consumed over typical 24 hoursWater, juices, sodas over typical 24 hoursFood allergies or intolerancesFeeding habits and techniques (bottle propping, grazing)Eating habits outside the home (day care, school)Vitamin, herbal, other supplements

Physical Exam

Helps identify chronic illness, syndromes

  • Weight, length/height, head circumference
  • Vital signs, pain
  • General: activity level (lethargic, hyperactive), caregiver-child interactions (eye contact, physical approximation, checking), hygiene, dysmorphic features, lymphadenopathy
  • Head: dry, dull, or absent hair; fontanelle size
  • Eyes: palpebral fissures, conjunctival pallor, strabismus, cataracts, retinal hemorrhages
  • Ears: malposition, otitis
  • Mouth, throat: anatomic abnormalities of palate or tongue, glossitis, cheilosis, gum bleeding, thrush, dental abnormalities, enlarged tonsils
  • Cardiac: murmur; abnormal femoral pulses
  • Chest, lungs: retractions, wheezes, crackles
  • GI: distention, masses, hepatomegaly
  • Anogenital: malformations; severe rashes; anal fissures, hemorrhoids
  • Musculoskeletal: frontal bossing, rachitic rosary, extremity bowing, wrist widening, edema, decreased muscle mass
  • Skin: eczema; hives; scaling; spoon-shaped nails; patterned bruises, scars, burns
  • Neurologic: cranial nerve palsies, hyper- or hypotonia, retention of primitive reflexes

Diagnostic Tests & Interpretation

Initial Lab Tests

  • CBC: anemia; leukemia
  • Comprehensive metabolic panel (CMP), phosphorus: malnutrition; metabolic abnormalities; chronic endocrine, liver, and renal disease
  • Thyroid function tests
  • UA and culture: renal tubular acidosis, infection

Follow-Up Tests & Special Considerations

  • Ferritin
  • Lead
  • Vitamin D
  • Purified protein derivative (PPD)
  • HIV, hepatitis B and C
  • Stool pathogens, Giardia antigen
  • Stool fat
  • Sweat test
  • Serum IgA, antitransglutaminase antibodies: celiac disease
  • Karyotype: Turner syndrome

Diagnostic Procedures/Other

  • Wrist x-rays: bone age
  • Chest x-ray: cardiac anomalies, cystic fibrosis
  • Lateral neck x-ray: adenotonsillar hypertrophy
  • Skeletal survey: suspected maltreatment
  • Upper GI series, pH probe: anatomic abnormalities, reflux
  • ECG

Treatment

Medication

Medications that stimulate appetite and growth hormone therapy have not been extensively studied in FTT. Nutritional supplements and calorie-dense foods help promote catch-up growth.

Additional Therapies

  • Community-based nutritional and psychosocial counseling program when no underlying illness. Multidisciplinary interventions including home nursing visits improve weight gain, parent-child relationships, and cognitive development.
  • Goal is catch-up growth (growth faster than normal rate for age). Normal growth rates for age average about 30 g/day until 3 months, 20 g/day from 3 to 6 months, 10 g/day from 6 to 12 months, and 8 g/day from 1 to 3 years.
  • Daily multivitamins, zinc, and iron

Issues for Referral

  • Subspecialty consultationMinimize risk of refeeding syndromeGenetic syndrome or disease suspected

Inpatient Considerations

Hospitalize when

  • FTT persists despite community-based dietary interventions
  • Severe malnutrition. Weight for age <60% of median or weight for height <70% of median increases morbidity.
  • Suspicion of abuse or neglect; note, this necessitates mandatory CPS report.

Ongoing Care

  • Monitoring should continue until weight for height deficit is repaired and child no longer needs a specialized diet to maintain normal growth. The Centers for Disease Control and Prevention (CDC) suggests World Health Organization growth charts for all children up to age 2 years and CDC growth charts for older children. Specialty growth charts for patients with genetic conditions can supplement these charts.

Additional Reading

  • Mash C, Frazier T, Nowacki A, et al. Development of a risk-stratification tool for medical child abuse in failure to thrive. Pediatrics. 2011;128(6):e1467-e1473. [View Abstract]
  • Olsen EM, Petersen J, Skovgaard AM, et al. Failure to thrive: the prevalence and concurrence of anthropometric criteria in a general infant population. Arch Dis Child. 2007;92(2):109-114. [View Abstract]
  • Rudolf MCJ, Logan S. What is the long term outcome for children who fail to thrive? A systematic review. Arch Dis Child. 2005;90(9):925-931. [View Abstract]
  • Shields B, Wacogne I, Wright CM. Weight faltering and failure to thrive in infancy and early childhood. BMJ. 2012;345:e5931. [View Abstract]
  • Wright C, Birks E. Risk factors for failure to thrive: a population-based survey. Child Care Health Dev. 2000;26(1):5-16. [View Abstract]

Codes

ICD09

  • 779.34 Failure to thrive in newborn
  • 783.21 Loss of weight
  • 783.3 Feeding difficulties and mismanagement
  • 783.41 Failure to thrive

ICD10

  • P92.6 Failure to thrive in newborn
  • R63.4 Abnormal weight loss
  • R63.3 Feeding difficulties
  • R62.51 Failure to thrive (child)

SNOMED

  • 433476000 failure to thrive in infant (disorder)
  • 267024001 abnormal weight loss (finding)
  • 274540003 Feeding difficulties and mismanagement (finding)
  • 432788009 pediatric failure to thrive (disorder)

FAQ

  • Q: How should weight gain while hospitalized be interpreted?
  • A: Children with and without medical illnesses will grow with sufficient caloric intake. Growth during hospitalization is not diagnostic of inorganic FTT.
  • Q: How often is organic disease the cause of FTT?
  • A: Organic disease is rare in children with FTT who are otherwise asymptomatic.