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Failure to Thrive, Emergency Medicine

Basics

Description

- No universally accepted definition - Failure to achieve or maintain a growth rate appropriate for age - Weight less than 2 standard deviations below normal for age (corrected for prematurity) and sex - Weight that crosses downward through 2 major percentiles (major percentiles are 5th, 10th, 25th, 50th, 75th, and 90th percentiles) on standard growth chart (see Additional Reading below) - There is an associated change in the velocity of growth of 1 or more growth parameters. Any of the 3 routinely monitored growth parameters may be impaired initially: - Weight loss initially followed by impaired growth in length/height and finally head circumference usually caused with caloric inadequacy. - Primary length/height fall-off often associated with endocrinology problem - Impairment in growth of head circumference commonly caused by CNS primary condition.

- Although the pattern is usually one of slow decrease in growth velocity, an abrupt change may occur, usually indicative of an organic origin. - Can manifest as: - Reduced muscle mass - Loss of subcutaneous fat - Alopecia - Dermatitis - Chronic disease - Marasmus - Kwashiorkor - Associated endocrinologic findings - Abnormal neurologic exam and development - Decreased immunologic function and increased risk of infection

- Detailed feeding history: - Breast-feeding: - Prior breast-feeding experience - Frequency of feedings - Length of feedings - Family support for breast-feeding

- Solid foods - Vomiting associated with feeds - Urine and stool output:

- Developmental history: - Achievement of appropriate milestones - Childs perceived temperament

- Chemistry panel (electrolytes, BUN, creatinine, glucose, liver function, protein, albumin, calcium, phosphate, magnesium): - Hydration and acidosis - Metabolic and endocrinologic disorders including thyroid disease. Often checking the routine newborn screening (NBS) is useful - Diabetes mellitus - Renal disease - Blood gas analysis - Renal tubular acidosis - Inborn errors of metabolism

- Cardiac: - Congenital heart disease - Cyanotic - Congestive - Acquired heart disease

- Pulmonary: - Bronchopulmonary dysplasia - Obstructive sleep apnea - Chronic lung disease - Cystic fibrosis

- Hematologic/oncologic: - Iron-deficiency anemia - Thalassemia - Lead poisoning - Leukemia

- Renal: - Chronic renal insufficiency - Renal tubular acidosis - Recurrent UTIs

- Neurologic/CNS: - Hydrocephalus - Hypertonia/hypotonia - Generalized weakness (i.e., spinal muscular atrophy) - Oromotor dysfunction

- Infectious: - Genetic/congenital: - Fetal alcohol syndrome - Smith-Lemli-Opitz syndrome - Cleft lip/palate - Inborn errors of metabolism - Many genetic syndromes can contribute.

- Nonorganic causes: - Parent-child dysfunction: - Mother-infant bonding problems - Maternal mental illness/substance abuse - Inexperienced mother - Breast-feeding difficulties - Improper formula preparation - Inadequate availability of formula - Chaotic family environment - Child abuse or neglect - Munchhausen syndrome by proxy

  • Not a single disease, but a description of a group of symptoms
  • Inadequate physical growth:Usually diagnosed earlier than age 2 yr
  • Broadly divided into:Organic (underlying medical condition)Nonorganic (no underlying medical condition)
  • Found in all socioeconomic groups
  • Poverty increases risk of failure to thrive (FTT)
  • May result in long-term growth, behavioral, and developmental difficulties, particularly in children who fail to thrive in the first few months of life

Etiology

Many diseases with unique causes resulting in 1 or more of:

  • Inadequate caloric intake
  • Inadequate caloric absorption, malabsorption
  • Excessive caloric expenditure
  • These may be secondary to underlying chronic disease

Diagnosis

Signs and Symptoms

  • No universally accepted definition
  • Failure to achieve or maintain a growth rate appropriate for age
  • Weight less than 2 standard deviations below normal for age (corrected for prematurity) and sex
  • Weight that crosses downward through 2 major percentiles (major percentiles are 5th, 10th, 25th, 50th, 75th, and 90th percentiles) on standard growth chart (see Additional Reading below)
  • There is an associated change in the velocity of growth of 1 or more growth parameters. Any of the 3 routinely monitored growth parameters may be impaired initially:Weight loss initially followed by impaired growth in length/height and finally head circumference usually caused with caloric inadequacy.Primary length/height fall-off often associated with endocrinology problemImpairment in growth of head circumference commonly caused by CNS primary condition.
  • Although the pattern is usually one of slow decrease in growth velocity, an abrupt change may occur, usually indicative of an organic origin.
  • Can manifest as:Reduced muscle massLoss of subcutaneous fatAlopeciaDermatitisChronic diseaseMarasmusKwashiorkorAssociated endocrinologic findingsAbnormal neurologic exam and developmentDecreased immunologic function and increased risk of infection

History

  • Detailed feeding history:Breast-feeding:Prior breast-feeding experienceFrequency of feedingsLength of feedingsFamily support for breast-feedingFormula:Type of formula (milk, soy, elemental, preemie)How formula is prepared (ready to feed, powder, liquid concentrate)Frequency of feedingsVolume per feedingSolid foodsVomiting associated with feedsUrine and stool output:
  • Gestational history:Maternal medical complicationsDrug or alcohol use
  • Birth history:Complications, intrauterine growth retardation, prematurityBirth weightCongenital anomaliesIntrauterine exposures/infections
  • Developmental history:Achievement of appropriate milestonesChilds perceived temperament
  • Psychosocial history:Family compositionFamily/social supportStressesMaternal depressionAbuse or neglect

Physical Exam

  • Weight, length/height, head circumference:Plotted on appropriate growth chart:Include as many prior growth points as possible
  • Dysmorphic features:Cardiac disordersPulmonary disordersGI disorders
  • Skin exam to include signs of child abuse

Essential Workup

  • Detailed history and physical exam
  • Growth parameters plotted on appropriate growth charts
  • Observation of family-child interaction
  • Direct observation of feeding
  • CBC, CRP, electrolytes, urinalysis and urine culture, and if indicated, lead level

Diagnosis Tests & Interpretation

Lab

  • CBC:AnemiaInfectionLeukemia/malignancyLead levelLead poisoning
  • Chemistry panel (electrolytes, BUN, creatinine, glucose, liver function, protein, albumin, calcium, phosphate, magnesium):Hydration and acidosisMetabolic and endocrinologic disorders including thyroid disease. Often checking the routine newborn screening (NBS) is usefulDiabetes mellitusRenal diseaseBlood gas analysisRenal tubular acidosisInborn errors of metabolism
  • Urinalysis with culture:
  • HIV
  • Stool studies including occult blood, culture, and ova and parasites

Imaging

Diagnostic Procedures/Surgery

  • pH probe:
  • Sweat chloride test:Cystic fibrosis (may be part of NBS)
  • Tuberculin skin testing

Differential Diagnosis

  • Organic causes:GI:Malabsorption syndromesCeliac diseaseCystic fibrosisFood allergyInflammatory bowel diseaseHepatobiliary diseaseHepatitisCirrhosisBiliary atresiaObstructive diseasePyloric stenosisMalrotationHirschsprung diseasePancreatitisShort gut syndromeGastroesophageal refluxVitamin deficienciesCardiac:Congenital heart diseaseCyanoticCongestiveAcquired heart diseasePulmonary:Bronchopulmonary dysplasiaObstructive sleep apneaChronic lung diseaseCystic fibrosisHematologic/oncologic:Iron-deficiency anemiaThalassemiaLead poisoningLeukemiaRenal:Chronic renal insufficiencyRenal tubular acidosisRecurrent UTIsNeurologic/CNS:HydrocephalusHypertonia/hypotoniaGeneralized weakness (i.e., spinal muscular atrophy)Oromotor dysfunctionImmunologic:Endocrine:Diabetes mellitusThyroid/parathyroid diseaseAdrenal diseaseGrowth hormone deficiencyHypopituitarismHypophosphatemic ricketsInfectious:Genetic/congenital:Fetal alcohol syndromeSmith-Lemli-Opitz syndromeCleft lip/palateInborn errors of metabolismMany genetic syndromes can contribute.Toxic
  • Nonorganic causes:Parent-child dysfunction:Mother-infant bonding problemsMaternal mental illness/substance abuseInexperienced motherBreast-feeding difficultiesImproper formula preparationInadequate availability of formulaChaotic family environmentChild abuse or neglectMunchhausen syndrome by proxy

Treatment

Initial Stabilization/Therapy

  • Check for hypoglycemia
  • Fluid resuscitation when dehydrated
  • Supportive/nonjudgmental environment

Ed Treatment/Procedures

  • Recognize/identify child with FTT
  • Rule out organic abnormalities:Organic causes may have specific treatments.
  • Social services consult
  • Breast-feeding consult:Advise on appropriate feeding.

Medication

Dependent on underlying cause

Follow-Up

Disposition

Admission Criteria

  • Organic cause requiring medical admission
  • Nonorganic causes to observe caregiver-child interaction
  • Nonorganic causes to observe weight while monitoring oral intake. This is particularly appropriate in children <3-6 mo of age because of the potential impact upon cognitive development
  • Suspected child abuse/neglect
  • Severe dehydration, malnutrition, or electrolyte imbalance

Discharge Criteria

  • Case appropriately managed by primary care physician
  • Follow-up is adequate to provide close monitoring of intake and growth.

Issues for Referral

Subspecialty referral depending on cause

Additional Reading

  • Bithoney WG, Dubowitz H, Egan H. Failure to thrive/growth deficiency. Pediatr Rev. 1992;13(12):453-460.
  • Block RW, Krebs NF, American Academy of Pediatrics Committee on Child Abuse and Neglect, et al. Failure to thrive as a manifestation of child neglect. Pediatrics. 2005;116:1234-1237.
  • Centers for Disease Control and Prevention, National Center for Health Statistics: Growth charts. Available at www.cdc.gov/growthcharts. Accessed on April 23, 2005.
  • Corbett SS, Drewett RF. To what extent is failure to thrive in infancy associated with poorer cognitive development? A review and meta-analysis. J Child Psychol Psychiatry. 2004;45:641-654.
  • Gahagan S, Holmes R. A stepwise approach to evaluation of undernutrition and failure to thrive. Pediatr Clin North Am. 1998;45(1):169-187.
  • Maggioni A, Lifshitz F. Nutritional management of failure to thrive. Pediatr Clin North Am. 1995;42:791-810.
  • McDougall P, Drewett RF, Hungin AP, et al. The detection of early weight faltering at the 6-8-week check and its association with family factors, feeding and behavioural development. Arch Dis Child. 2009;94:549-552.
  • Shah MD. Failure to thrive in children. J Clin Gastroenterol. 2002;35(5):371-374.

Codes

ICD9

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

ICD10

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

SNOMED

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