Overview
Definition:
Failure to thrive (FTT) is a clinical term describing inadequate growth in a child
It is typically defined as weight below the third percentile for age and sex on standardized growth charts, or a significant downward deviation in weight percentile (two major percentiles) over time
It is not a diagnosis but a sign of an underlying problem.
Epidemiology:
FTT affects approximately 5-10% of infants and children seen in primary care settings, with higher prevalence in disadvantaged populations
It is more common in infants under one year of age
Specific incidence varies by socioeconomic status and access to healthcare.
Clinical Significance:
FTT is a critical indicator of potential health problems, ranging from nutritional deficiencies to serious underlying medical or psychosocial issues
Early identification and intervention are crucial to prevent long-term physical and developmental sequelae, improving overall child health and well-being.
Caloric Assessment
Definition Of Goal:
Determining the total daily caloric intake required for adequate growth and weight gain in a child with FTT.
Estimation Methods:
Estimates are typically based on age, weight, activity level, and underlying medical conditions
General guidelines exist: infants (0-6 months) require 100-120 kcal/kg/day
older infants and young children (6-12 months) require 90-100 kcal/kg/day
toddlers (1-3 years) require 70-85 kcal/kg/day
older children (3-10 years) require 60-70 kcal/kg/day
These are baseline values.
Detailed History:
Comprehensive dietary history from caregivers including: feeding patterns, volume and frequency of feeds, type of formula or breast milk, introduction of solids, use of pacifiers, duration of feeds, child's cues for hunger and satiety, and any feeding difficulties (e.g., gagging, spitting up, poor latch).
Tracking Intake:
Utilize a detailed food diary for 3-7 days to objectively record all intake, including snacks and liquids
Observe feeding sessions to assess technique, duration, and child's engagement
Caloric content of specific foods and formulas should be calculated accurately.
Assessing Output:
Monitor urine output and stool frequency/consistency
Dehydration can mimic poor intake
Excessive stool output may indicate malabsorption or increased metabolic rate
Bowel movements should be assessed for frequency, consistency, and presence of steatorrhea.
Diagnostic Approach
History Taking:
Detailed birth history, developmental milestones, feeding history, family history of growth issues or genetic disorders, social and environmental factors (e.g., poverty, parental mental health, domestic violence, parental education and understanding of nutrition), previous medical history, and any specific symptoms of illness.
Physical Examination:
Thorough anthropometric measurements (weight, height, head circumference) plotted on growth charts
Assess for signs of dehydration, pallor, dysmorphic features, organomegaly, rickets, signs of chronic illness (e.g., cardiac murmurs, respiratory distress), and neurological status
Observe child's interaction and alertness.
Laboratory Investigations:
Initial labs typically include: Complete Blood Count (CBC) to assess for anemia
Electrolytes, Blood Urea Nitrogen (BUN), Creatinine to evaluate hydration and renal function
Liver Function Tests (LFTs) and Renal Function Tests (RFTs)
Thyroid Stimulating Hormone (TSH) for hypothyroidism
Stool examination for occult blood, reducing substances, ova, and parasites
Urine analysis for infection or metabolic disorders
Depending on suspicion, further tests like celiac screen, vitamin levels, or genetic testing may be indicated.
Imaging Modalities:
Skeletal survey may be considered if rickets is suspected
Abdominal imaging (ultrasound or X-ray) might be useful to rule out structural abnormalities or masses
Chest X-ray if respiratory symptoms are present
Echocardiogram if cardiac issues are suspected.
Differential Diagnosis
Inadequate Caloric Intake:
Organic causes: GERD, dysphagia, cleft palate, pyloric stenosis, neurological impairment affecting feeding
Non-organic causes: neglect, poverty, parental lack of knowledge or resources, behavioral feeding problems, strict or inadequate feeding regimens.
Malabsorption:
Celiac disease
Cystic fibrosis
Lactose intolerance
Short bowel syndrome
Allergic enteropathy (e.g., cow's milk protein allergy)
Giardiasis
Chronic pancreatitis
Symptoms include steatorrhea, abdominal distension, diarrhea.
Increased Metabolic Demand:
Chronic illness: Congenital heart disease (e.g., VSD, PDA), chronic lung disease (e.g., bronchopulmonary dysplasia), hyperthyroidism, chronic infections (e.g., HIV, TB), malignancy
These conditions increase caloric requirements significantly.
Nutrient Deficiencies:
Iron deficiency anemia, Vitamin D deficiency (rickets), Zinc deficiency, other micronutrient deficiencies can impair growth independently and complicate overall nutritional status.
Genetic And Endocrine Disorders:
Turner syndrome, Down syndrome, Prader-Willi syndrome, Russell-Silver syndrome, endocrine disorders such as growth hormone deficiency or hypothyroidism.
Management
Initial Management:
Address any immediate life threats
Stabilize hydration and electrolyte balance
Initiate appropriate nutritional support based on caloric assessment
Educate and support caregivers.
Nutritional Rehabilitation:
Gradual increase in caloric density of feeds, often starting with fortified formulas or breast milk
If oral intake is insufficient, consider nasogastric (NG) or orogastric (OG) tube feeding
Parenteral nutrition may be required in severe cases with malabsorption or intractable vomiting.
Medical Management:
Treat any identified underlying medical conditions (e.g., GERD with PPIs, hypothyroidism with levothyroxine)
Address specific deficiencies (e.g., iron supplementation for anemia, vitamin D for rickets).
Behavioral And Psychosocial Support:
For non-organic FTT, this is paramount
Provide counseling and education to caregivers on appropriate feeding practices, responsive feeding, and child development
Social work referral for assistance with resources
Occupational and speech therapy may be beneficial for feeding difficulties.
Monitoring And Follow Up:
Regular monitoring of growth parameters (weight, height, head circumference) plotted on growth charts
Frequent follow-up appointments to assess progress, adjust caloric intake, and reinforce caregiver education
Multidisciplinary team approach is often best.
Complications
Early Complications:
Electrolyte imbalances
Dehydration
Hypoglycemia
Hypothermia
Congestive heart failure (due to fluid overload)
Nutritional deficiencies (anemia, rickets).
Late Complications:
Impaired cognitive development
Behavioral problems
Delayed puberty
Stunted growth
Increased susceptibility to infections
Long-term nutritional deficiencies.
Prevention Strategies:
Antenatal education on infant nutrition
Early identification of risk factors and prompt intervention
Comprehensive feeding support for mothers and infants
Regular well-child check-ups with accurate growth monitoring
Addressing psychosocial stressors impacting caregivers.
Key Points
Exam Focus:
FTT is a sign, not a diagnosis
Caloric needs are individualized
Differentiate between organic and non-organic causes
Growth charts are essential tools
Multidisciplinary approach is key for management.
Clinical Pearls:
Always plot growth parameters on standardized charts
Observe feeding interactions directly if possible
Trust, but verify caregiver-reported intake
Consider psychosocial factors as much as organic ones
Start with realistic caloric goals and increase gradually.
Common Mistakes:
Attributing FTT solely to poor intake without thorough investigation
Not plotting growth parameters correctly or regularly
Underestimating the role of psychosocial factors
Inadequate nutritional follow-up and caregiver support
Delaying intervention for suspected organic causes.