Failure to Thrive

Suzanne Swanson Mendez,

MD
August 31, 2012

Defining FTT
Growth Deficiency
Crossing 2 major
percentile lines or a
term child less than 5th
percentile on growth
chart
A child under 6 months
who has not grown for
2 months
A child over 6 months
has not grown for 3
months

http://www.mashby.com/images/posts/skinn
y_kid.gif

Types of Growth Deficiency

Type Growth Chart
Findings

Etiology

WEIGHT decreased
more than height,
Normal head
circumference (OFC).

Most common. From

inadequate intake,
inadequate absorption,
increased metabolism, or
defective utilization of
calories.

WEIGHT AND HEIGHT

both decreased
proportionally, normal
OFC.

Familial short stature,

endocrinopathies,
constitutional growth delay,
skeletal dysplasias.

WEIGHT, HEIGHT, OFC

all decreased versus
normal.

CNS abnormalities,
chromosomal defects, in
utero/perinatal insults.

Type 1A: Inadequate

intake
Incorrect preparation of formula:

too dilute or

too concentrated

Breastfeeding difficulties
Unsuitable feeding habits for age:

excessive
juices, food fads, poor transition to food (6-12 months)

Behavioral problems affecting eating

Poverty and food shortages
Disturbed parent-child relationship: neglect or
hypervigiliance

Mechanical feeding difficulties:

oromotor
dysfunction, congenital anomalies, severe reflux, CNS
damage

Type 1B: Inadequate

absorption of calories

Celiac disease
Cystic fibrosis
Cows milk protein allergy
Vitamin or mineral deficiencies
(acrodermatitis enteropathica, scurvy)

Biliary atresia or liver disease

Short gut syndrome

Type 1C: Increased

metabolism
Hyperthyroidism
Hypoxemia
Chronic lung disease
Congenital heart defect
Severe obstructive sleep apnea

Chronic disease
HIV/Immunodeficiency
Renal disease
Malignancy

Type 1D: Defective

utilization of calories
Genetic
abnormalities
(Trisomy 13, 18, 21)

Congenital
infections
Metabolic disorders
(storage diseases, amino acid
disorders)

Case One
CJ, an 8-month-old male presents for WCC
Last seen at 6 months with poor weight
gain, increased calorie formula
recommended
Plotting his weight, you notice that he has
crossed from the 95th percentile (at 2
months of age) to the 5th percentile now
What would you do?

Workup
History and physical will identify etiology
in most cases
What do you want to know?
Pregnancy/birth history:
IUGR, congenital infections, risk factors for HIV,
prenatal care and labs
Gestational age at birth, size at birth (SGA?)
Newborn screen
What does the newborn screen include in D.C.?
When is it done?

History and Physical

Diet/Feeding history:
How much does the baby eat? How is formula
mixed? (What? When? Where? With whom? How?)
Food battles

Stooling/Voiding patterns
Vomiting or signs of reflux after feeds?
PMH: Hospitalizations, Recurrent
infections?
Growth curve: growth velocity is most important and
can point out when failure began.

Medications/Herbs/Supplements

More History
Allergies
Environmental and
Toxin Exposures
Social History: risks for
feeding problems

Family History: includes

parental heights

Developmental History
Review of Systems

Expected Feeding and

Voiding Patterns
Age

Feeds

Calories
Required

Voids/Stools

Neonate

8-12
feeds/day;
5.5oz/kg/d

100-110 kcal/kg/d

6-8 wet diapers,

at least 2
stools/day

2-4 months

6-8 feeds;

90-100 kcal/kg/d

>3-4 wet diapers,

stool freq varies

70-90 kcal/kg/d

varies

18-24oz/day

5-12
months

24-32oz/day

>5 years

3 meals, 2
snacks

plus solids
1500 kcal (for first varies
20 kg) + 25 kcal
for each additional
kg

Signs of successful
breastfeeding
1) Weight gain; no more than 10% loss from BW in 1st
week
2) Baby calm, relaxed after feed; no more hunger cues
3) Feeds 8-12 times/day
4) Swallowing may be heard
5) Steady rhythmic motion in cheeks
6) >6 soaking wet (or heavy) diapers/day
7) Stools change to yellow by 7th day of life, at least 1-2
stools/day until 5-6 weeks of age
8) Breasts feel softer/emptier after feed
At 4-6 weeks, may pull away if flow decreases--->
compress to increase flow; not a sign of less milk

Further workup of Growth

Deficiency
From the mother in Case One:
Prenatal/birth history: Had regular prenatal care,
prenatal labs normal, HIV negative; Born by NSVD at
39 wks, home with mom on DOL 2. NB screen
normal.
Nutrition/Feeding history:
For first 2 months, breastfed only and did well (95th%)
Then started refusing to eat, breastfed at night only for 5
min q2hrs. Often vomited during feedings when upset.
Started on 24kcal formula during day at 6 months by
pediatrician due to poor wt gain but often refused to drink.
Does not seem to like any pureed foods: turns head away.

Feeding and Voiding

Feeding history: No difficulties with
swallowing, no diaphoresis or tiring with
feeds, but vomiting has become a daily
event--mom blames his temper
Voiding/stooling patterns:
3 wet diapers/day;
Stools every 3-4 days
No steatorrhea or blood/mucus noted in
stools
Stools are yellow to green and soft, usually
large amounts

Constipation
Is this baby constipated?
Infrequent stooling does not necessarily
mean constipation nor does straining
Worry about constipation if:
Pain or crying during passage of BM
Unable to pass BM after straining/pushing over
10 minutes
No BM after more than 3 days (except if breastfed
and over 1 month--may have 5-6 days btwn stools)

How much does this baby

weigh?
For an estimate of average
for age:
Newborn: 3.2 kg
Ages 3-12 months
[for weight in kg]:
Age (in months) + 9
2
But in an emergency, use
the color-coded tape!

The First Year

Baby should regain BW by 2 weeks (earlier
if formula fed)
Doubles BW by 4-5 months
Triples BW by 1 year, quadruples by 2
Height does not double until 3-4 years
OFC reflects neuronal cell division from 06 months; later from neuronal cell growth
and supporting tissue proliferation

Expected Growth
Age

DAILY
weight gain

Height
Increase

OFC
increase

0-3
months

20-30 grams

3.5cm/month 2 cm/month

3-6
months

15-20 grams

2 cm/month

6-9
months

10-15 grams

1.5cm/month 0.5 cm/mon

9-12
months

8-12 grams

1.2cm/month 0.5cm/mon

1 cm/month

Growth history
BW 3.4kg (at 39 wks)
6.8 kg at 2 months
(95th percentile)

7 kg at 6 months
(10th percentile)

7.1 kg at 8 months
(5th percentile)

Height/OFC both
near 50th
percentile

http://www.keepkidshealthy.com/growthch
arts/boysbirth.gif

History (continued)
PMH/PSH: No hospitalizations or surgeries, no
recurrent infections, no risk factors for HIV, NB
screen in Virginia was normal, AOM at 6 months.

Medications: none, no herbs, no

supplements
Allergies: no known drug allergies, no
known food allergies
ROS: no snoring/apnea noted, but not a
good sleeper and mom thinks he cries a lot.
No tachypnea, no choking or diaphoresis
during feeds; otherwise unremarkable.

More History:
Developmentally, he cruises and says mama
and dada, but has quite a temper according to
mom.
Family history: mid-parental height is at 50th
percentile (dads + moms height in cm +/- 13) div by 2
Social history:
Father works as engineer, moved from China 2 years
ago
First child; lives only with mom and dad now, but
grandmother lived with family for childs first 2 months
then returned to Taiwan
Moms English skills very limited

Screening for social factors

No longer organic versus nonorganic
FTT; many cases multifactorial
Caregiver depression/attachment disorder:
can affect babys growth especially in the first 6 months

Anxiety disorder or separation/

individuation disorder: may affect babys growth
from 6-12 months

Child abuse or neglect always a concern

Maternal depression
One of the most common complications of pregnancy
10-20% of women experience depression during or
within the first 12 months after pregnancy
Pediatrician often has more contact with mothers
than their PCPs do yet less than 10% screen
2 easy questions:
During the past month, have you been bothered by
feeling down, depressed, or hopeless?
During the past month, have you been bothered by
having little interest or pleasure in doing things?
*Parents might respond better to paper questionnaire

Further social history

CJs mom does
admit to feeling
very isolated and
screens + for
anhedonia
Does not drive and
is alone with infant
in apartment all
day
Nearest friends 30
miles away

Physical Exam
Physical exam: weight 7.1kg (5th
percentile), height 69 cm (25th percentile),
OFC 45 cm (50th percentile)
Fussy but consolable
Observed feeding: Mom offers bottle
but baby gets irritable, refuses. Mom
very anxious.
Description of formula mixing correct
Physical exam otherwise unremarkable

Nutrition
* A prospective 3-day diet record is helpful
in most cases of growth deficiency
* In this case, baby refusing feeds and
vomiting when upset were interfering with
adequate caloric intake

Types of Growth Deficiency

Type Growth Chart
Findings

Etiology

WEIGHT decreased
more than height,
Normal head
circumference (OFC).

Most common. From

inadequate intake,
inadequate absorption,
increased metabolism, or
defective utilization of
calories.

WEIGHT AND HEIGHT

both decreased
proportionally, normal
OFC.

Familial short stature,

endocrinopathies,
constitutional growth delay,
skeletal dysplasias.

WEIGHT, HEIGHT, OFC

all decreased versus
normal.

CNS abnormalities,
chromosomal defects, in
utero/perinatal insults.

Labs for Case One

Screening Hb, Pb levels normal for age
Confirm NB screen results
Other labs should be guided by detailed
H&P
In CJs case, physical was unrevealing and
history + observation suggests parentchild interaction problem
Later pH probe negative for GERD

Management
Depends on underlying
cause
For CJ, counseling for
mother was
recommended
Increased social
support
Vomiting improved with
behavioral
management, less
force-feeding and
decreased parental
anxiety.

Case Two
AB, a 12-month-old infant, presents to Urgent
Care for fever, ear pain
T 38 C, HR 130, RR 24, sat 100% RA
Wt 7.1 kg (at 3rd percentile for age)
History of fever for 2 days with cough for 1 wk
Mom also reports baby has had loose stools
for months but no vomiting.
Stools are yellow to green without blood or mucus;
occur 3-4 times/day.

Normal urine output with light yellow urine.

What else do you want to know?

History
PMH/PSH: Born at term, no problems with
pregnancy, NB screen negative. BW 3.8kg.
Multiple episodes of AOM, last 1 month
ago. Also hospitalized 1x for bronchiolitis
and once for pneumonia, no surgeries.
Medications: High-dose amox completed 2
1/2 weeks ago
Allergies: NKDA, no known food allergies
Family history: Mid-parental height at 75th
%, mom has Type I diabetes

Further history
No growth chart available, but mom thinks
child hasnt gained wt in months: much
smaller than other kids her age.
Nutrition history: breastfed until 2 months
and then switched to formula and did well.
At 4 months, rice cereal introduced, then
pureed foods at 6 months. Now eats
everything--all table foods.

Social and developmental

history
Developmentally appropriate: sat at 6
months, first words at 8 months, now can
walk with both hands held
Social history:
Parents separated 7 months ago; father no
longer involved
Mom works part-time; estimates income at
$20,000/year
Has neighbors who cares for child while she
works
History of depression; denies feeling depressed
currently but is very worried about her daughter

What next for AB?

More history?
Physical exam: wt 7.1 kg (3rd%), L 70 cm (10th
%), and OFC 46 cm (50th%)
What do these parameters suggest about her
growth deficiency?
Can be Type I (chronic malnutrition) or Type II
growth deficiency:
Familial short stature/Constitutional growth delay
Endocrinopathy
Skeletal dysplasias
*Though her weight is still more affected than her height

Physical exam
Child is thin, but alert, interactive, in no distress
HEENT: Thin, wispy blonde hair; R TM reddened
and retracted, L TM with typmanosclerosis; Tonsils
2+, no lymphadenopathy.
Heart exam normal
Lungs have transmitted upper airway sounds but
good aeration.
Abdomen is soft but very full/ protuberant, no HSM
Tanner I GU, good femoral pulses
Extremities are thin but well-perfused; no signs of
dehydration, no edema
Skin warm, pink, without rashes

Differential diagnosis?
Type I Growth Deficiency:

Inadequate caloric intake

Increased metabolism
Inadequate absorption
Defective utilization

Type II Growth Deficiency: since height is

also affected (but still less so than weight)

Familial short stature

Constitutional growth delay
Skeletal dysplasias
Endocrinopathies

Workup
You send her home with a
prospective 3-day food diary and
Augmentin and a WIC referral
Encourage social support for mom
3 meals/3 snacks on a daily schedule
for child
Any labs?

Labs
CBC
for anemia, malignancy,
immunodeficiency

Electrolytes and UA
for renal/metabolic disease

Albumin and LFTs

for abdominal workup

Stool studies:
wbc/rbc smear, O&P

Sweat chloride test

HIV, consider quantitative
immunoglobulins

Lab Results
CBC shows normocytic
anemia
Lytes, UA normal
Albumin low at 2.3
mg/dl
Stool studies negative
for wbc, rbc, O&P
Sweat chloride normal
HIV negative
QuIgs normal
(including IgA)

Follow-up
Two weeks later, the child returns and
mom seems happier, but AB has only
gained 0.05 kg (about 3g/day)
How much should she be gaining?

Answer: about 8 g/day just for normal growth, not including

catch-up

Nutrition diary reveals an intake of 800

kcal/day (about 85 kcal/kg of IDEAL body
weight/day)--is this enough?

Answer: It might be enough for normal growth, but she will

need more to catch up (up to 1.5 x more)

Differential diagnosis now

Type I growth deficiency:
Inadequate intake? Not according to food diary
Increased metabolism? Not HIV/renal disease,
unlikely malignancy or CHD/CLD
Inadequate absorption? Could be celiac disease;
unlikely CF (sweat Cl normal) or vitamin def.
Defective utilization? No signs of genetic
abnormalities, congenital infections, or
metabolic disorders

Type II growth deficiency less likely without

family history, signs of endocrinopathy

Further work-up
Given her low albumin with normal
kcal intake for age and chronic
diarrhea, malabsorption is likely
Stool reducing subs/alpha-1-AT sent
Screening test for celiac disease:
Anti-tissue transglutaminase Ab (IgA and IgG)

also sent

TGA comes back +

Management
AB is switched to a
gluten-free diet and
starts to gain weight
well
Small bowel biopsy
confirms diagnosis
Height also improves
Pt continues to do well
with close followup
and social situation
improves

Importance of treating
Growth Deficiency
Early childhood is a key period for growth
and development.
Often multifactorial in etiology
Children with failure to thrive are at risk
for:
Behavioral problems
Developmental delay
Short stature

Prompt intervention and close follow-up

needed to reverse FTT pattern and prevent
associated problems

On the path to good

health!

Bibliography

Behrman RE, The First Year, Nelson Textbook of Pediatrics, Chapter 10,
17th edition, 2004.
Brayden RM, Daley MF, Brown JM, Ambulatory and Community Pediatrics:
Growth Deficiency, Current Pediatric Diagnosis & Treatment, 16th edition,
2003, p 239-240.
Gahagan, Sheila, Failure to Thrive: A Consequence of Undernutrition,
Pediatrics in Review 2006;27:e1-e11.
Krebs NF, Hambidge KM, Primak LE, Normal Childhood Nutrition & Its
Disorders, Current Pediatric Diagnosis & Treatment, 16th edition, 2003, p.
277-307.
Krugman S and Dubowitz H, Failure to Thrive, American Family Physician,
68:5, Sept. 2003.
LPCH Health Library: Constipation. Pediatric Housecall Online. Barton
Schmidt, Updated Aug. 2002.
http://www.lpch.org/HealthLibrary/ParentCareTopics/AbdomenGISymptoms/C
onstipation.html
Robertson J, Shilkofski N, Johns Hopkins Hospital, Normal Nutrition and
Growth, Chapter 20, The Harriet Lane Handbook, 17th edition, August
2005.

Bibliography

(continued)

Save Babies Through Screening Foundation, Disorders

Screening for in State NBS Programs and Puerto Rico,
Updated June 18, 2006. http://www.savebabies.org/states/washingtonDC.php
Food Stamp Program, Food and Nutrtion Services Home
Page, Last updated October 11, 2006.
http://www.fns.usda.gov/fsp/faqs.htm#2

Flora, B, Breastfeeding Essentials: Is My Baby Getting

Enough? Last updated April 2003.
http://breastfeeding.hypermart.net/enoughmilk.html

Johnson CP and Blasco PA, Infant Growth and

Development, Pediatrics in Review. 18:7, July 1997.

Women, Infants, and Children, Food and Nutrition Service, USDA,

Last updated June 20, 2005.

http://www.fns.usda.gov/wic/

D.C. Newborn Screening

1) 3-Methylcrotonyl-CoA carboxylase deficiency (3MCC)

2) 3-OH 3-CH3 glutaric aciduria (HMG)
3) Argininosuccinic acidemia (ASA)
4) Beta-Ketothiolase deficiency (BKT)
5) Biotinidase deficiency (BIOT)
6) Carnitine uptake defect (CUD)
7) Citrullinemia (CIT)
8) Classical galactosemia (GALT)
9) Congenital adrenal hyperplasia (21-hydroxylase
deficiency) (CAH)
10) Congenital hypothyroidism (CH)
11) Cystic fibrosis (CF)
12) Glutaric acidemia type I (GA 1)
13) Hb S/C disease (Hb S/C)
14) Hb S/-thalassemia (Hb S/Th)
15) Homocystinuria (due to CBS deficiency) (HCY)
16) Isovaleric acidemia (IVA)
17) Long-chain L-3-OH acyl-CoA dehydrogenase deficiency
(LCHADD)
18) Maple syrup disease (MSUD)
19) Medium-chain acyl-CoA dehydrogenase deficiency
(MCADD)
20) Methylmalonic acidemia (Cbl A,B) (Cbl A, B)
21) Methylmalonic acidemia (mutase deficiency) (MUT)
22) Multiple carboxylase deficiency (MCD)
23) Phenylketonuria (PKU)
24) Propionic acidemia (PROP)
25) Sickle cell anemia (Hb SS disease) Hb (SS)
26) Trifunctional protein deficiency (TFP)
27) Tyrosinemia type I (TYR I)
28) Very long-chain acyl-CoA dehydrogenase deficiency
(VLCADD)

29) 2-Methyl 3-hydroxy butyric aciduria (2M3HBA)

30) 2-Methylbutyryl-CoA dehydrogenase deficiency (2MBG)

31) 3-Methylglutaconic aciduria (3MGA)

32) Argininemia (ARG)
33) Biopterin cofactor biosynthesis, defects of (BIOPT BS)
34) Biopterin cofactor regeneration, defects of (BIOPT REG)
35) Carnitine palmitoyltransferase I deficiency (liver) (CPT
IA)
36) Carnitine palmitoyltransferase II deficiency (CPT II)
37) Carnitine: acylcarnitine translocase deficiency (CACT)
38) Citrullinemia type II (CIT II)
39) Dienoyl-CoA reductase deficiency (DE RED)
40) Galactokinase deficiency (GALK)
41) Galactose epimerase deficiency (GALE)
42) Glutaric acidemia Type II (GA 2)
43) Hypermethioninemia (MET)
44) Hyperphenylalaninemia, benign (H-PHE)
45) Isobutyryl-CoA dehydrogenase deficiency(IBG)
46) Malonic acidemia (MAL)
47) Medium/short-chain L-3-OH acyl-CoA dehydrogenase
deficiency (M/SCHADD)
48) Medium-chain ketoacyl-CoA thiolase deficiency (MCKAT)
49) Methylmalonic acidemia (Cbl C,D) (Cbl C,D)
50) Short-chain acyl-CoA dehydrogenase deficiency
(SCADD)
51) Tyrosinemia type II (TYR II)
52) Tyrosinemia type III (TYR III)
53) Variant Hb-pathies (including HB E) (Var Hb)

Food insecurity

What social
programs might
help this family?
Food stamps
WIC

http://www.singlesourcephoto.com/vermont/
images/vt/vtc0072bg.jpg

Federal Poverty Guidelines

Federal Poverty Guideline 2006: Annual
income of $16,600 or below for family of 3
Food stamp program
For families with gross income of 130% or below
FPG (net income 100% or less)
All family members must provide a SSN or apply
for one
Limited to US citizens except for many children,
elderly immigrants, those working in U.S. for a
certain amount of time
Average monthly benefit $86/person;
$200/household

WIC
WIC (Women, Infants, and Children):
Federal grant program
Provides supplemental nutritious foods, nutrition
education, screening and referrals for
pregnant/breastfeeding women and children up to
age 5
Gross income at or below 185% of FPG
($30,710 for a family of 3 for July 2006-June 2007)

Serves 45% of all infants in the U.S.

Nutrition risk requirement: Must be seen by a
health professional (may be in WIC clinc for free) and
have height/weight recorded and screen for
anemia.