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Failure to Thrive (FTT)

by Elizabeth J. Palumbo, MD

Failure to thrive is weight consistently below the 3rd to 5th percentile for age and sex, progressive decrease in weight to below the 3rd to 5th percentile, or a decrease in the percentile rank of 2 major growth parameters in a short period. The cause may be an identified medical condition or may be related to environmental factors. Both types relate to inadequate nutrition. Treatment aims to restore proper nutrition.

Etiology

The physiologic basis for failure to thrive (FTT) of any etiology is inadequate nutrition and is divided into

  • Organic FTT

  • Nonorganic FTT

Organic FTT

Growth failure is due to an acute or chronic disorder that interferes with nutrient intake, absorption, metabolism, or excretion or that increases energy requirements (see Some Causes of Organic Failure to Thrive). Illness of any organ system can be a cause.

Some Causes of Organic Failure to Thrive

Mechanism

Disorder

Decreased nutrient intake

Cleft lip or palate

CNS disorder (eg, cerebral palsy)

Gastroesophageal reflux disease

Parasites

Pyloric stenosis

Rumination

Malabsorption

Celiac disease

Cystic fibrosis

Disaccharidase (eg, lactase) deficiency

Inflammatory bowel disease

Short gut

Impaired metabolism

Chromosomal abnormality (eg, Down syndrome, Turner syndrome)

Fructose intolerance

Galactose-1-phosphate uridyl transferase deficiency (classic galactosemia)

Inborn errors of metabolism

Increased excretion

Diabetes mellitus

Proteinuria

Increased energy requirements

Bronchopulmonary dysplasia

Cystic fibrosis

Heart failure

Hyperthyroidism

Infection

Nonorganic FTT

Up to 80% of children with growth failure do not have an apparent growth-inhibiting (organic) disorder; growth failure occurs because of environmental neglect (eg, lack of food), stimulus deprivation, or both.

Lack of food may be due to

  • Impoverishment

  • Poor understanding of feeding techniques

  • Improperly prepared formula (eg, overdiluting formula to stretch it because of financial difficulties)

  • Inadequate supply of breast milk (eg, because the mother is under stress, exhausted, or poorly nourished)

Nonorganic FTT is often a complex of disordered interaction between a child and caregiver. In some cases, the psychologic basis of nonorganic FTT seems similar to that of hospitalism, a syndrome observed in infants who have depression secondary to stimulus deprivation. The unstimulated child becomes depressed, apathetic, and ultimately anorexic. Stimulation may be lacking because the caregiver

  • Is depressed or apathetic

  • Has poor parenting skills

  • Is anxious about or unfulfilled by the caregiver role

  • Feels hostile toward the child

  • Is responding to real or perceived external stresses (eg, demands of other children in large or chaotic families, marital dysfunction, a significant loss, financial difficulties)

Poor caregiving does not fully account for all cases of nonorganic FTT. The child’s temperament, capacities, and responses help shape caregiver nurturance patterns. Common scenarios involve parent-child mismatches, in which the child’s demands, although not pathologic, cannot be adequately met by the parents, who might, however, do well with a child who has different needs or even with the same child under different circumstances.

Mixed FTT

In mixed FTT, organic and nonorganic causes can overlap; children with organic disorders also have disturbed environments or dysfunctional parental interactions. Likewise, children with severe undernutrition caused by nonorganic FTT can develop organic medical problems.

Diagnosis

  • Frequent weight monitoring

  • Thorough medical, family, and social history

  • Diet history

  • Laboratory testing

Children with organic FTT may present at any age depending on the underlying disorder. Most children with nonorganic FTT manifest growth failure before age 1 yr and many by age 6 mo. Age should be plotted against weight, height, and head size on growth standards and growth charts, such as those recommended by the WHO and the Centers for Disease Control and Prevention (CDC). (For children 0 to 2 yr, see WHO Growth Charts ; for children 2 yr and older, see CDC Growth Charts .) Until premature infants reach 2 yr, age should be corrected for gestation.

Weight is the most sensitive indicator of nutritional status. When FTT is due to inadequate caloric intake, weight falls from the baseline percentile before length does. Reduced linear growth usually indicates severe, prolonged undernutrition. Simultaneous fall off of length and weight suggests a primary disorder of growth. Because the brain is preferentially spared in protein-energy undernutrition (see Protein-Energy Undernutrition), reduced growth in head circumference occurs late and indicates very severe or long-standing undernutrition. Children who are underweight may be smaller and shorter than their peers and may present with fussiness or crying, lethargy or sleepiness, and constipation. FTT is associated with physical delays (eg, sitting, walking), social delays (eg, interacting, learning), and, if occurring in older children, delayed puberty.

Usually, when growth failure is noted, a history (including diet history— Essentials of the History for Failure to Thrive) is obtained, diet counseling is provided, and the child’s weight is monitored frequently. A child who does not gain weight satisfactorily in spite of outpatient assessment and intervention usually is admitted to the hospital so that all necessary observations can be made and diagnostic tests can be done quickly. Without historic or physical evidence of a specific underlying etiology for growth failure, no single clinical feature or test can reliably distinguish organic from nonorganic FTT. Because nonorganic FTT is not a diagnosis of exclusion, the physician should search simultaneously for an underlying physical problem and for personal, family, and child-family characteristics that support a psychosocial etiology. Optimally, evaluation is multidisciplinary, involving a physician, a nurse, a social worker, a nutritionist, an expert in child development, and often a psychiatrist or psychologist. The child’s feeding behaviors with health care practitioners and with the parents must be observed, whether the setting is inpatient or outpatient.

Engaging the parents as co-investigators is essential. It helps foster their self-esteem and avoids blaming parents who may already feel frustrated or guilty because of a perceived inability to nurture their child. The family should be encouraged to visit as often and as long as possible. Staff members should make them feel welcome, support their attempts to feed the child, and provide toys and ideas that promote parent-child play and other interactions. Staff members should avoid any comments implying parental inadequacy, irresponsibility, or other fault as the cause of FTT. However, parental adequacy and sense of responsibility should be evaluated. Suspected neglect or abuse must be reported to social services, but in many instances, referral for preventive services that are targeted to meet the family’s needs for support and education (eg, additional food stamps, more accessible child care, parenting classes) is more appropriate.

During hospitalization, the child’s interaction with people in the environment is closely observed, and evidence of self-stimulatory behaviors (eg, rocking, head banging) is noted. Some children with nonorganic FTT have been described as hypervigilant and wary of close contact with people, preferring interactions with inanimate objects if they interact at all. Although nonorganic FTT is more consistent with neglectful than abusive parenting, the child should be examined closely for evidence of abuse (see Child Maltreatment). A screening test of developmental level should be done and, if indicated, followed with more sophisticated assessment. Hospitalized children who begin gaining weight well with proper feeding techniques, formula preparation, and amount of calories are more likely to have nonorganic FTT.

Essentials of the History for Failure to Thrive

Item

Comments

Growth chart

Measurements, including those taken at birth if possible, should be examined to determine the trend in growth rate. Because of wide normal variations, diagnosis of failure to thrive should not be based on a single measurement, except when undernutrition is obvious.

Diet history (3 days)

Diet history should be detailed, including feeding schedule and techniques for the preparation and feeding of formula or adequacy of breast milk supply. As soon as possible, parents should be observed feeding the infant to evaluate their technique and the infant’s vigor of sucking. An infant who tires easily during feeding may have underlying cardiac or pulmonary disease. Enthusiastic burping or rapid rocking of the infant during feeding may result in excessive regurgitation or even vomiting. A disinterested parent may be depressed or apathetic, suggesting a psychosocial environment that is lacking stimulation for and interaction with the infant.

Assessment of the child’s elimination pattern

Abnormalities of urine or stool and frequent emesis should trigger an investigation to detect underlying renal disease, malabsorption syndrome, pyloric stenosis, or gastroesophageal reflux.

Medical history and birth history

Of concern is any evidence of intrauterine growth restriction or prematurity with growth delay that has not been compensated; developmental delay; unusual, prolonged, or chronic infections (eg, TB, parasitic, HIV); neurologic, cardiac, pulmonary, or renal disease; illness or hospitalization; and possible food intolerance.

Family history

Included is information about familial growth patterns, especially in parents and siblings; the occurrence of diseases known to affect growth (eg, cystic fibrosis); and a parent’s recent physical or psychiatric illness resulting in inability to provide consistent stimulation and nurturance.

Social history

Attention is focused on family composition, socioeconomic status, desire for pregnancy with and acceptance of the child, and stresses (eg, job changes, family moves, separation, divorce, deaths, other losses).

Testing

Extensive laboratory testing is usually nonproductive. If a thorough history or physical examination does not indicate a particular cause, most experts recommend limiting screening tests to

  • CBC with differential

  • ESR

  • BUN and serum creatinine and electrolyte levels

  • Urinalysis (including ability to concentrate and acidify) and culture

  • Stool for pH, reducing substances, odor, color, consistency, and fat content

Depending on prevalence of specific disorders in the community, blood lead level, HIV, or TB testing may be warranted.

Other tests that are sometimes appropriate include a thyroxine level if growth in height is more severely affected than growth in weight or when height and weight fall off simultaneously (in which case growth hormone deficiency should also be suspected) and a sweat test if the child has a history of recurrent upper or lower respiratory tract disease, a salty taste when kissed, a ravenous appetite, foul-smelling bulky stools, hepatomegaly, or a family history of cystic fibrosis. Investigation for infectious diseases should be reserved for children with evidence of infection (eg, fever, vomiting, cough, diarrhea); however, a urine culture may be helpful because some children with FTT due to UTI lack other symptoms and signs. Radiologic investigation should be reserved for children with evidence of anatomic or functional pathology (eg, pyloric stenosis, gastroesophageal reflux). However, if an endocrine cause is suspected, bone age is sometimes determined.

Prognosis

Prognosis with organic FTT depends on the cause. With nonorganic FTT, the majority of children age > 1 yr achieve a stable weight above the 3rd percentile. Children who develop FTT before age 1 yr are at high risk of cognitive delay, especially verbal and math skills. Children diagnosed at age < 6 mo, when the rate of postnatal brain growth is maximal, are at highest risk. General behavioral problems, identified by teachers or mental health practitioners, occur in about 50% of children. Problems specifically related to eating (eg, pickiness, slowness) or elimination tend to occur in a similar proportion of children, usually those with other behavioral or personality disturbances.

Treatment

  • Sufficient nutrition

  • Treatment of underlying disorder

  • Long-term social support

Treatment aims to provide sufficient health and environmental resources to promote satisfactory growth. A nutritious diet containing adequate calories for catch-up growth (about 150% of normal caloric requirement) and individualized medical and social supports are usually necessary. Ability to gain weight in the hospital does not always differentiate infants with nonorganic FTT from those with organic FTT; all children grow when given sufficient nutrition. However, some children with nonorganic FTT lose weight in the hospital, highlighting the complexity of this condition.

For children with organic or mixed FTT, the underlying disorder should be treated quickly. For children with apparent nonorganic FTT or mixed FTT, management includes provision of education and emotional support to correct problems interfering with the parent-child relationship. Because long-term social support or psychiatric treatment is often required, the evaluation team may be able only to define the family’s needs, provide initial instruction and support, and institute appropriate referrals to community agencies. The parents should understand why the referrals are being made and, if options exist, should participate in decisions concerning which agencies will be involved. If the child is hospitalized in a tertiary care center, the referring physician should be consulted regarding local agencies and the level of expertise available in the community.

A predischarge planning conference involving hospital-based personnel, representatives from the community agencies that will provide follow-up services, and the child’s primary physician is ideal. Areas of responsibility and lines of accountability must be clearly defined, preferably in writing, and distributed to everyone involved. The parents should be invited to a summary session after the conference so that they can meet the community workers, ask questions, and arrange follow-up appointments.

In some cases, the child must be placed in foster care. If the child is expected to eventually return to the biologic parents, parenting skill training and psychologic counseling must be provided for them. Their child’s progress must be monitored scrupulously. Return to the biologic parents should be based on the parents’ demonstrated ability to care for the child adequately, not only on the passage of time.

Key Points

  • FTT should be suspected in children with a significant drop in percentile rank on growth parameters or a consistently low rank (eg, below 3rd to 5th percentile).

  • Organic FTT is due to a medical disorder (eg, malabsorption, inborn error of metabolism).

  • Nonorganic FTT is due to psychosocial problems (eg, neglect, poverty).

  • In addition to a taking a thorough medical, social, and dietary history, health care providers should observe parents/caregivers feeding the child.

  • Hospitalization may be necessary to evaluate the child, to observe the child's response to appropriate feeding, and to involve a feeding team if needed.

Resources In This Article

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