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Failure to thrive (FTT) is weight consistently below the 3rd to 5th percentile for age, 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 FTT of any etiology is inadequate nutrition and is divided into
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 Table 2: Miscellaneous Disorders in Infants and Children: Some Causes of Organic Failure to Thrive ). Illness of any organ system can be a cause.
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Table 2
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| Some Causes of Organic Failure to Thrive |
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Mechanism
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Disorder
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Decreased nutrient intake
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Cleft lip or palate
CNS disorder
Gastroesophageal reflux disease
Pyloric stenosis
Rumination
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Malabsorption
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Celiac disease
Cystic fibrosis
Disaccharidase (eg, lactase) deficiency
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Impaired metabolism
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Fructose intolerance
Inborn errors of metabolism
Galactose-1-phosphate uridyl transferase deficiency (classic galactosemia)
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Increased excretion
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Diabetes mellitus
Proteinuria
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Increased energy requirements
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Bronchopulmonary dysplasia
Cystic fibrosis
Heart failure
Hyperthyroidism
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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
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
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, those with severe undernutrition caused by nonorganic FTT can develop organic medical problems.
Diagnosis
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. Until premature infants reach 2 yr, age should be corrected for gestation.
Weight is the most sensitive indicator of nutritional status. Reduced linear growth usually indicates more severe, prolonged undernutrition. Because the brain is preferentially spared in protein-energy undernutrition (see Undernutrition: Protein-Energy Undernutrition), reduced growth in head circumference occurs late and indicates very severe or long-standing undernutrition.
Usually, when growth failure is noted, a history (including diet history—see Table 3: Miscellaneous Disorders in Infants and Children: 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 those 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.
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Table 3
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| Essentials of the History for Failure to Thrive |
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Item
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Comments
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Growth chart
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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.
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Diet history (3 days)
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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, the parents should be observed feeding the infant to evaluate their technique and the infant's vigor of sucking. An infant who tires easily may have underlying exercise intolerance. Enthusiastic burping or rapid rocking 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.
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Assessment of the child's elimination pattern
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Abnormal losses through urine, stool, or emesis are investigated to detect underlying renal disease, malabsorption syndrome, pyloric stenosis, or gastroesophageal reflux.
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Medical history and birth history
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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.
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Family history
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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.
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Social history
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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).
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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
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 electrolyte concentrations if the child has a history of significant vomiting or diarrhea; a thyroxine level if growth in height is more severely affected than growth in weight; 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). Radiologic investigation should be reserved for children with evidence of anatomic or functional pathology (eg, pyloric stenosis, gastroesophageal reflux).
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
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.
Last full review/revision March 2009 by Elizabeth J. Palumbo, MD
Content last modified March 2009
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