FAILURE TO THRIVE

FAILURE TO THRIVE

I. Problem. At a well-child visit, a 4-month-old infant is noted to have

fallen below the third percentile for weight.

II. Immediate Questions

A. What is patient’s height (recumbent length in infant) and head

circumference?

 Failure to thrive (FTT) is growth failure confined

to weight, unless the deprivation is of long duration. Low weight

for height suggests a short-term problem. Low weight and height,

or head circumference, or all three, suggests long-term deprivation

or organic disease rather than familial disease.

B. What are past growth parameters?

 Evaluate the growth trend.

Values that consistently fall below the 3rd percentile support an

etiology of prematurity, familial, or chronic disease. FTT is often

defined as a 2-standard–deviation decline in weight velocity (two

major percentile lines on growth curve).

C. What is patient’s feeding history?

 FTT is undernutrition, regardless

of etiology. Decreased caloric intake is the most common

cause, but FTT may also result from increased caloric requirements

or decreased absorption of calories. Ask about appetite,

routine meals, and fluid intake (what is offered and when). Specific

questions include:

1. Is formula mixed properly? Overly dilute formula results in

decreased caloric intake.

2. How much formula does infant actually ingest from each

bottle?

3. Is there evidence of effective breast feeding (eg, latching on,

milk production, time at breast)?

4. Are other foods and fluids being offered?

D. Any feeding difficulties?

 In an infant, choking, slow feeding,

tiring with feeding, poor suck, vomiting, or regurgitation suggests

GI, cardiac, or neurologic disorder. In a toddler or older child with

decreased appetite, consider dental disease, constipation, chronic

illness, or apathy.

E. What is the prenatal history and birth history?

 Relevant information

includes maternal nutrition, prenatal laboratory values,

perinatal infections, illnesses, medications, delivery complications,

extended nursery or NICU stay, and newborn screening

tests.

F. Has patient achieved normal developmental milestones?

Developmental delays may provide clues to the cause of FTT.

FTT itself can cause delay.

G. What is the past medical history?

Hospitalizations, recurrent

infections, and chronic diarrhea suggest chronic disease

.

H. What medication(s) does patient take?

 Ask about prescribed,

over-the-counter, and alternative remedies.

I.                   What is the social history?

II.                Specific questions include:

1. Who is primary caregiver?

2. Who lives at home?

3. Who cares for patient if caregiver is away?

4. Any changes in family dynamics?

J. Family history?

 Relevant information includes siblings or parents

with chronic disease or recurrent infection, chromosomal or metabolic

abnormality, fetal or infant deaths, and stature and growth

trends, including FTT.

K. Interaction among patient, caregiver, and family?

 FTT usually

involves environmental or psychosocial factors, or both. Child maltreatment

and neglect take many forms, from overt physical and

emotional abuse to nonintentional neglect.

III.             Differential Diagnosis.

 FTT is a sign, not a diagnosis. The cause of

the undernutrition must be determined. Most patients are younger than

3 years of age. Often FTT may involve a combination of organic (ie,

major disease process or single organ dysfunction) and environmental

or psychosocial factors (ie, no distinct pathophysiologic abnormality

but, rather, insufficient emotional-physical nurturing). Presence of

one factor does not preclude a search for others.

A-Environmental, Psychosocial, or Nonorganic FTT.

 Most

common type in the United States. Includes neglect (intentional,

nonintentional), feeding issues (decreased amount, improper

mixing of formula, poor technique), poverty (food unavailable),

and parental incompetence (maternal depression, substance

abuse, diminished mental capacity).

B. Congenital or Anatomic Anomalies.

 Chromosomal defect, congenital

anomalies, cardiac defect, infection, cystic fibrosis, in utero

exposure to toxins.

C. GI Abnormalities. Gastroesophageal reflux disease, milk-protein

intolerance, celiac disease, Hirschsprung disease, irritable bowel

disease, malabsorption, malrotation.

D. Renal Disorders.

 Occult UTI, renal tubular acidosis, chronic renal

insufficiency.

E. Cardiac Disorders.

 Persistent patent ductus arteriosus, acquired

heart disease, congestive heart failure.

F. Pulmonary Disorders. Bronchopulmonary dysplasia, poorly controlled

asthma, chronic aspiration.

G. Infectious Diseases.

 HIV, tuberculosis, parasitic infestations,

dental disease.

H. Metabolic Alterations.

Inborn errors, galactosemia, amino or

organic acidurias, storage diseases, hypercalcemia.

I.                   Endocrine Disorders.

 Thyroid, parathyroid, adrenal, pituitary, or

growth hormone disorders; diabetes mellitus type 1.

J. Neurologic Disorders. Degenerative disorders, cerebral palsy,

oral motor dysfunction, structural defects.

K. Medications.

 Prescribed, over-the-counter, and alternative

remedies.

L. Other Causes.

 Malignancy, sickle cell disease, environmental

toxins (lead).

IV. Database. Further evaluation (laboratory and other studies) is rarely

useful unless suggested by history or physical exam findings.

A. Physical Exam Key Points

1. Growth parameters.

 Plot height (if age > 2 years) or recumbent

length (if < 2 years), weight, and head circumference on a

standard growth chart

2. Overall appearance and behavior.

 Assess for eye contact,

interaction, inappropriate behaviors, dysmorphic features,

signs of endocrine or metabolic disease, psychosocial neglect,

or emotional abuse.

3. Signs of malnutrition.

 Loss of subcutaneous fat, muscle wasting,

sparse hair or alopecia, cheilosis, hydration.

4. Signs of maltreatment or neglect. Cutaneous injuries (eg,

bruises, burns, unusual marks) or poor hygiene.

5. HEENT.

 Fontanelle, funduscopic exam, neck masses, dental

disease, tonsillar or sinus disease, cleft palate or lip.

6. Cardiopulmonary system. Abnormal chest wall, evidence of

reactive airway disease, atypical murmur or abnormal heart

sounds, digital clubbing.

7. Abdomen.

 Protuberance, organomegaly.

8. Neurologic exam.

 Abnormal muscle tone and strength, coordination,

deep tendon reflexes.

B. Laboratory Data.

 Initial laboratory tests to consider in severe

cases include CBC, electrolytes, BUN and creatinine, total CO2 or

HCO3, urine culture, HIV, and PPD. Order other tests as dictated

by history and exam findings.

C. Radiographic and Other Studies. These tests have minimal

yield if not suggested by history or exam findings. Perform skeletal

survey, if maltreatment is suspected.

V. Plan

A. Hospitalization. Admit patients with severe malnutrition or when

infant or child is at risk for harm, follow-up is not reliable, caregiver

is neither competent nor compliant, or outpatient management

fails.

B. Parental Education and Training. Key component of treatment,

regardless of cause. Avoid placing blame. Parents may require

referral to nutritional, occupational therapy, physical therapy, psychiatric,

and social services.

C. Psychosocial Causes. Ensure that home environment is safe,

caregiver is competent and compliant, and follow-up is reliable.

1. Infants. Observe feeding techniques.

2. Toddlers. Institute routine mealtimes, offer solids before liquids,

and limit juice or water.

D. Organic Causes. Treat underlying condition. Institute slow introduction

of high-calorie foods, with close monitoring.

E. Caloric Supplementation. Depends on specific diagnoses and

severity.Patients often require 50% increase in caloric requirements.

F. Follow-up. Frequent follow-up and close monitoring of growth

and development are important because patients are at risk for

cognitive and developmental delays.

VI. Problem Case Diagnosis. Exam findings in the 4-month-old infant

were normal except for loss of subcutaneous fat, and interaction with

family was appropriate. Mother reported that she had been mixing

2 cans of water to every can of formula concentrate, “trying to make

ends meet.” This provided two thirds of infant’s required caloric intake

per day (13.3 cal/oz rather than 20 cal/oz). Diagnosis is FTT caused

by environmental factors.

VII. Teaching Pearl: Question. If a healthy thriving infant shows a

decline over two or more major percentiles late in infancy, is this

cause for concern?

128 I: ON CALL PROBLEMS

VIII. Teaching Pearl: Answer. Normal changes in linear growth occur in

infants. Studies show that healthy thriving infants channel to higher

or lower percentiles over the first 18 months of life, at times crossing

over two or more major percentiles, then staying within that new

channel of growth.

REFERENCES

Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics, 17th

ed. Saunders, 2004.

Gahagan S, Holmes R. A stepwise approach to evaluation of undernutrition and failure

to thrive. Pediatr Clin North Am 1998;45:169–187.

Schwartz ID. Failure to thrive: An old nemesis in the new millennium. Pediatr Rev

2000;21:257–264.