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Failure to Thrive

Basics
DESCRIPTION
A descriptive term for poor growth as a result of inadequate nutrition from a variety of possible causes.

Definition:
1. Weight for age <5th or 3rd percentile, or weight velocity depression crossing 2 percentile lines are most
frequently used.
2. Often linear growth and head circumference are less affected than weight, if at all.
3. Growth charts which correct for regression to the mean can be used.

Degree of malnutrition can be assessed using the Gomez criteria:


1. Compare current weight for age with 50th percentile weight (expected weight) for the same age.

Weight <60% of expected is considered severe failure to thrive (FTT).

6175% = moderate FTT

7690% = mild FTT

EPIDEMIOLOGY
BASICS-EPIDEMIOLOGY-Prevalence

Prevalence of FTT ranges from 1.321%, depending on definitions used and populations studied.

Definitions vary among studies.

In the 1980s, FTT accounted for 15% of tertiary hospital admissions for young infants. Up to 10% of infants in
some primary care settings show signs of FTT.

Diagnosis
Goal: When diagnosis of FTT has been established, the first goal is to identify possible organic causes, nonorganic causes,
and normal variants of growth. There may be more than one contributing factor.

Careful attention to accurate plotting of growth parameters is necessary.

Use standard growth charts. Trends of growth parameters over time are most useful, and can point to underlying
causes or normal variants.

Modified growth charts for specific populations or specific ethnicities can be helpful.

With poor nutrition, weight is the 1st parameter to drop:


1. If weight is the only parameter down, then consider acute undernutrition.
2. If height is also depressed, consider chronic malnutrition, called stunting.
3. Symmetric poor growth including head circumference suggests congenital infections or exposures,
chromosomal abnormalities, or severe malnutrition.

FTT often has negative connotations that can introduce feelings of incompetence or be associated with judgments.

SIGNS AND SYMPTOMS


History
History must be obtained with a focus on maintaining family trust and participation:

Dietary history must include questions about:


1. Who feeds and who prepares food for the child
2. Specific foods/formulas
3. Amounts or volumes of foods/formulas
4. Frequency of intake
5. Behaviors taking place around mealtimes
6. Distinct foods and beverages: Remember excessive juice and water intake as possible contributors to poor
growth.
7. Formula preparation must be reviewed, as overly dilute or concentrated preparations may result in poor
growth.
8. Dietician input can help quantify caloric intake.

A thorough psychosocial history should include:


1. Assessment of pregnancy history
2. Parental mental health
3. Intellectual capacity and social circumstances
4. Identification of the caregivers
5. Possible problems with alcohol or drugs
6. Stressors: Economic or intrafamilial
7. Previous history of neglect or Child Protective Services referrals

Family history should be obtained, assessing for the following:


1. Systemic diseases like inflammatory bowel disease, asthma, cystic fibrosis
2. FTT, particularly in siblings
3. Short stature

Review of systems:
1. Developmental history with focus on any developmental problems
2. History of recurrent infections
3. Vomiting
4. Reflux
5. Stool: Diarrhea, pattern, frequency, consistency, presence of blood or mucus

Respiratory symptoms:

1. Chronic cough
2. Shortness of breath
3. Snoring
Physical Exam

Plot on standard growth charts: www.cdc.gov/growthcharts


1. Weight (without clothes)
2. Height (or length in <2 year old)
3. Head circumference

Assess for the following:


1. Dysmorphic features
2. Physical signs of neglect or abuse
3. Skin for rashes, neurocutaneous lesions
4. Hair, thin or sparse (indicating malnutrition)
5. Mouth for:

Clefts

Quality of sucking movements

Dental carries

Cheilosis (suggesting vitamin deficiencies)

6. Chest exam for signs of chronic respiratory or cardiac disease


7. Abdomen for distention (possibly due to malabsorption) or organomegaly
8. Loose skin of the buttocks, indicative of general muscle wastage
9. Edema, signifying protein deficiency
10. Neurologic exam for evidence of cerebral palsy or other abnormalities that might compromise food intake
11. Observing the interaction between a parent and child, especially during a feeding session, may be
extremely useful.
TESTS
LABORATORY

In general, after a proper history and physical exam, few tests are of diagnostic assistance.

Random screening is not recommended.

Reasonable initial screening tests include:


1. CBC (for anemia or malignancy)
2. ESR

3. Comprehensive metabolic panel including electrolytes, BUN, creatinine, liver function tests, calcium,
magnesium, and phosphorus(to evaluate for metabolic or renal disorders, liver disease, and [in severe
malnutrition] as a baseline to prevent electrolyte abnormalities associated with refeeding)
4. Urine for culture and urinalysis (for UTI and renal tubular acidosis)

Other possible tests based on history and physical (not an exhaustive list):
1. Immunoglobulins
2. Celiac screen (and total IgA)
3. Thyroid function tests
4. Blood glucose
5. Iron studies
6. Lead level
7. Stool sample
8. Stool microscopy and culture
9. Stool fat
10. PPD
11. HIV screening
12. Urine organic and serum amino acids(metabolic screen)
13. Karyotype
14. Allergy investigations: RAST, skin prick test
15. Sweat test
16. Endoscopy
17. Bone age x-rays
18. EKG
DIFFERENTIAL DIAGNOSIS

Normal variants of growth not considered FTT include:


1. Infants who drop to a lower growth percentile, and then continue on that percentile (called regression
toward the mean or drop down growth)
2. Trisomy 21 infants (special growth charts should be used; see Down Syndrome chapter), trisomy 18 or
13, or congenital infections
3. Infants with a history of intrauterine growth retardation (IUGR) or prematurity:

Corrections for gestational age are necessary until at least 2 years of age.

As long as growth continues along one percentile line, even if below the 5th percentile, FTT
should not be diagnosed.

4. Constitutional delay in growth

5. Familial short stature

Pathologic or organic causes can be classified into the following categories:


1. Insufficient caloric intake (the most common cause) which includes:

Decreased appetite

Inappropriate type or volume of food (commonly excess juice)

Incorrect dietary beliefs

Maternal depression

Problems with parent/child interaction

Parent drug/alcohol use

Poor feeding technique

Incorrect formula preparation

Oromotor dysfunction or cleft palate

Central nervous system insults, including cerebral palsy and degenerative diseases

Child abuse/neglect and withholding of food must be considered.

Chronic illnessassociated anorexia

2. Inadequate absorption or utilization includes:

Gastroesophageal reflux disease

Malabsorption

Maldigestion

Vomiting from obstruction, increased intracranial pressure, medications, or illnesses such as


urinary tract infection, or metabolic disorders (storage diseases, amino acid disorders)

Celiac disease

Allergic colitis

Cystic fibrosis

Inflammatory bowel disease

Cows milk protein allergy

Lactose intolerance

Biliary atresia

Liver disease

Hirschsprung disease

Malrotation

Chronic constipation

Short-gut syndrome

Vitamin or mineral deficiencies, such as acrodermatitis enteropathica, scurvy

3. Excess metabolic demand, including chronic disease states such as:

Cardiac disease

Chronic lung disease

Endocrine disorders, e.g., diabetes mellitus or diabetes insipidus, hyperthyroidism, adrenal or


pituitary disease

Anemia, sickle cell disease, thalassemia

Genetic/chromosomal abnormalities (trisomy 21)

Treatment
INITIAL STABILIZATION

If severe FTT is diagnosed, hospitalization is required.

Avoid the refeeding syndrome, which may result in electrolyte disturbance and circulatory collapse.
GENERAL MEASURES

Treatment or management of any identified organic contributors is necessary, such as using an elemental formula in
the case of milk protein allergy.

Children with FTT need a high-calorie diet for catch-up growth, and all children with FTT need close follow-up.

Additional calories for catch-up growth are typically 150% of the caloric requirement for the expected, not actual,
weight.

A dietician/nutritionist can be helpful in setting goals and diet recommendations, which may include increased
protein with increased calories.

Catch-up growth (kcal/kg/d) guidelines for average replacement according to the patients age:
1. 10 days to 1 month, 120 kcal/kg/d
2. 12 months, 115 kcal/kg/d
3. 23 months,105 kcal/kg/d
4. 36 months, 95 kcal/kg/d
5. 6 months to 5 years, 90 kcal/kg/d

Vitamin and mineral supplementation may be required.

High-calorie concentrated supplementation may be needed if volume necessary for catch-up growth is not
tolerated.

If there is no improvement despite increase in calories, a multidisciplinary approach is recommended, even for mild
or moderate FTT.

Multidisciplinary approach includes doctors, nurses, dietitians, social workers, and psychologists.

Follow-up Recommendations

The FTT child should remain under long term surveillance for growth and cognitive development.

If the child is judged to be at risk, mandatory reporting to Child Protective Services, based on local guidelines,
must be followed.

Very young children should be followed every 1 or 2 weeks, and older children at least monthly until catch-up
growth is demonstrated and a positive trend is maintained.
DISPOSITION

Admission Criteria

Most cases of FTT can be managed as outpatients by the primary care practitioner. Admit all severe FTT patients
and patients with moderate dehydration or infection. Consider social factors in admission.

Consider admission for observation of feeding, parentchild interaction, and dietary habits, as well as the ability to
perform specific tests; consult subspecialists.
Discharge Criteria

Discharge may be considered when:

Diagnostic tests and consultations requiring hospitalization have been performed (i.e., pH probe, sweat test,
occupational therapy evaluation of swallowing).

Adequate weight gain has been demonstrated.

Proper follow-up has been set in place.

The caretaker has demonstrated an understanding of nutrition recommendations and growth expectations.
FOLLOWUP-DISPOSITION-Issues-for-Referral

In cases of continued poor growth, addressing psychosocial issues within the family is crucial and usually requires
involvement of a multidisciplinary team.

Child Protective Services involvement is required if neglect is suspected.

Frequently Asked Questions

Q: If a child gains weight in the hospital, does that prove that the FTT is from a nonorganic cause?

A: There is a misconception that weight gain in a hospital or strictly supervised environment rules out organic
causes. This is not the case; weight gain can be achieved in children with organic or nonorganic causes of FTT.

Q: When should a child with FTT be referred to Child Protective Services?

A: The primary physician must consider the childs overall well-being and possible effects on long-term
neurobehavioral development. Noncompliance with nutrition recommendations, failure to appear at follow-up or
other appointments, and other signs or symptoms of neglect are all reasons that would justify referral.