Failure to Thrive (FTT) in Children

The physiologic basis for failure to thrive (FTT) is inadequate nutrition Overview of Undernutrition Undernutrition is a form of malnutrition. (Malnutrition also includes overnutrition.) Undernutrition can result from inadequate ingestion of nutrients, malabsorption, impaired metabolism, loss... read more and is divided into

Most cases of FTT are mixed.

Age should be plotted against weight, height, and head size on growth standards and growth charts, such as those recommended by the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC). (For children 0 to 2 years, see WHO Growth Charts; for children 2 years and older, see CDC Growth Charts.) Until premature infants reach 2 years of age, age should be corrected for gestation.

Weight is the most sensitive indicator of nutritional status. Another useful measure of undernutrition includes a body mass index (BMI) Z-score of less than -2 (ie, 2 standard deviations below the mean BMI). 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 or height and weight suggests a primary disorder of growth or a prolonged inflammatory state.

Because the brain is preferentially spared in protein-energy undernutrition Protein-Energy Undernutrition (PEU) Protein-energy undernutrition (PEU), previously called protein-energy malnutrition, is an energy deficit due to deficiency of all macronutrients. It commonly includes deficiencies of many micronutrients... read more , 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 Evaluation Constipation is responsible for up to 5% of pediatric office visits. It is defined as delay or difficulty in defecation. Normal frequency and consistency of stool varies with children's age... read more . FTT is associated with physical delays (eg, sitting, walking), social delays (eg, interacting, learning), and, if occurring in older children, delayed puberty Delayed Puberty Delayed puberty is absence of sexual maturation at the expected time. Diagnosis is by measurement of gonadal hormones (testosterone and/or estradiol), luteinizing hormone, and follicle-stimulating... read more .

Usually, when growth failure is noted, a history (including diet history—see table ) is obtained, diet counseling is provided, and the child’s weight is monitored frequently.

Careful examination of the growth chart can lend clues to the diagnosis. For example, if the weight and height fall off simultaneously, a diagnosis of an organic disease is likely. 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 children may have both organic and nonorganic FTT, 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. 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.

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 Symptoms and Signs Child maltreatment includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (eg, clergy, coach, teacher) that results... read more . 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.

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. For hospitalized children, 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.

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.

Treatment of failure to thrive is aimed at providing 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.

Prognosis for organic FTT depends on the cause.

With nonorganic FTT, the majority of children age > 1 year achieve a stable weight above the 3rd percentile with appropriate management.

Children who develop any type of FTT before age 1 year are at high risk of cognitive delay, especially verbal and math skills. Children diagnosed at age < 6 months, 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.

The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.