Failure to Thrive
Mohammad F El-Baba, MD, Assistant Professor of Pediatrics, Division of Pediatric Gastroenterology, Wayne State University School of Medicine; Division Chief of Pediatric Gastroenterology, Children's Hospital of Michigan
Reda W Bassali, MBChB, Associate Professor, Departments of General Pediatrics and Adolescent Medicine, Medical College of Georgia; John Benjamin, MD, Chief, General Section of Pediatrics and Adolescent Medicine, Vice Chair for Clinical Activities, Professor, Department of General Pediatrics, Medical College of Georgia; Ruby Mehta, MD, Fellow, Division of Pediatric Gastroenterology, Children's Hospital of Michigan
Updated: May 4, 2009
Introduction
Background
Growth failure, or failure to thrive (FTT), is a descriptive term and not a specific diagnosis. This term is widely used to describe inadequate growth in early childhood. However, no consensus has been reached concerning the specific anthropometrical criteria to define this description. Although definitions vary, most authors use this term only when growth has been noted to be low or to have decreased over time. For instance, some authors define failure to thrive as height or weight less than the third to fifth percentiles for age on more than one occasion. Other authors cite height or weight measurements falling 2 major percentile lines using the standard growth charts of the National Center for Health Statistics (NCHS). Still others state that true malnutrition (weight <80% of ideal body weight for age) should be present to state a child is failing to thrive.
All authorities agree that only by comparing height and weight on a growth chart over time can failure to thrive be accurately assessed. Although measurements of head circumference are important in the evaluation of infants and toddlers, failure of the head to grow by itself is not part of the failure to thrive entity.1
Normal growth and growth charts of term and premature infants, as well as the etiology, evaluation, management, and outcome of failure to thrive are discussed in this article.
Pathophysiology
Normal growth in term infants
To recognize abnormal growth, one needs to understand normal growth. The average birth weight for a term infant is 3.3 kg. Weight drops as much as 10% in the first few days of life, probably as a result of loss of excess fluid; however, birth weight should be regained within 2 weeks after birth. Breastfed infants tend to regain birth weight a little later than bottle-fed infants.
The median increase in weight per day in children is summarized below. On average, infants gain 1 kg/mo for the first 3 months, 0.5 kg/mo from age 3-6 months, 0.33 kg/mo from age 6-9 months, and 0.25 kg/mo from age 9-12 months. Term infants double their birth weight by age 4 months and triple their weight by age 12 months.
Median daily weight gain by age groups is as follows:
0-3 months - 26-31 g
3-6 months - 17-18 g
6-9 months - 12-13 g
9-12 months - 9 g
1-3 years - 7-9 g
4-6 years - 6 g
Term infants grow 25 cm in length during the first year, 12.5 cm in the second year, and then slow down to approximately 5-6 cm between age 4 years and the onset of puberty, at which time growth can increase up to 12 cm per year.
The average head circumference is 35 cm at birth and increases rapidly to 47 cm by age 1 year; the rate of growth then slows, reaching an average of 55 cm by age 6 years.
Also, the upper-to-lower body segment ratio changes with growth. Normally, the ratio at birth is 1.7, the ratio at age 3 years is 1.3, and the ratio by age 7 years becomes 1.0. The lower body segment is the measurement of the symphysis pubis to the floor.
Normal growth in premature infants
When plotting growth charts for premature babies, a "corrected age" should be used. This corrected age can be calculated by subtracting the number of weeks of prematurity from the postnatal age. Special growth charts based on gestational age rather than chronological age have been developed for infants, beginning at 26 weeks' gestational age; however, because these charts represent a compilation of a relatively small number of infants, they may not be completely reliable. Whichever technique is used for premature babies (eg, adjustment of age, using specific premature growth charts), consistency of methodology is essential. Once a method for plotting growth is chosen, that technique should be followed each time plotting occurs.
After catch-up growth is attained, at approximately age 18 months for head circumference, age 24 months for weight, and age 40 months for height, normal growth charts can be used. In some premature babies with very low birth-weight, catch-up growth does not occur until early school age.
Growth charts
Growth charts were developed by the National Center for Health Statistics based on data collected through the Third National Health and Nutrition Examination Survey III. The growth charts, which have been used since 1977, are available for males and females aged 0-36 months and aged 2-18 years. The growth charts for boys and girls aged 0-36 months include weight and height for age and head circumference; growth charts for both age groups include weight for stature.
These charts have been revised and are available from the Centers for Disease Control and Prevention (2000 CDC Growth Charts: United States). The new charts are applicable to infants, children, and adolescents from birth to age 20 years and have 7 percentile curves (5th, 10th, 25th, 50th, 75th, 90th, 95th). Charts are available for use in subspecialty patients (eg, endocrine, gastroenterology) with additional third and 97th percentile curves.
Body mass index (BMI) charts, which are available for individuals aged 2-20 years, have replaced the weight-for-stature charts. BMI is calculated by dividing weight in kilograms by height in meters squared.
Accurate measurements are essential to the interpretation of growth charts. Scales need to be calibrated regularly; length should be measured carefully, and head circumference should be measured using standardized techniques.
Alternate growth charts are available for children with Down syndrome, Turner syndrome, meningomyelocele, low birth weight, and very low birth weight. No matter which growth chart is used, the most valuable information is obtained by careful measuring and plotting on the same chart over time. Infants and children remain within 1-2 percentile curves over time.
Frequency
United States
In reports from 1980-1989, failure to thrive accounted for 1-5% of tertiary hospital admissions for infants younger than 1 year. An estimated 10% of children in primary care settings show signs of failure to thrive.
International
In underdeveloped countries, malnutrition manifesting as failure to thrive is more common.
Mortality/Morbidity
Ultimate physical growth may be decreased in children with failure to thrive. Cognitive development is affected in children younger than 5 years who have failure to thrive. With improvement of nutritional status, these deficits may not be completely reversed. Traditionally, it has been thought that nonorganic causes of failure to thrive resulted in more cognitive deficits than are observed with organic causes. In developing countries, malnutrition is a significant cause of mortality, whether directly or secondary to complications (eg, infection).
Race
Failure to thrive can occur in all socioeconomic strata, although it is more frequent in families living in poverty. Studies indicate increased incidence in children receiving Medicaid, children living in rural areas, and children who are homeless.
Sex
Nonorganic failure to thrive is reported more commonly in females than in males.
Clinical
History
The most important part of the evaluation of children with failure to thrive (FTT) may be obtaining a careful detailed history. Once failure to thrive is identified in a particular child, an attempt then should be made to determine from the history whether nonorganic failure to thrive, organic failure to thrive, or a combination of the 2 is present. Prenatal history is extremely important and information regarding the following should be obtained:
Smoking
Alcohol consumption
Use of medications
Any illness during the pregnancy
Similarly, a history of any problems in the nursery should be obtained. Dietary history provides very important information. A simple formula for bottle-feeding infants to determine the proper number of ounces they should consume in 24 hours is to multiply the weight in kilograms by 5. (Calculation is reached by assuming that children need 100 kcal/kg and that each ounce of standard formula contains 20 kcal/oz; thus, for each kilogram of a child's weight, 5 [ie, 100 divided by 20] ounces are needed for proper growth and weight gain. For example, a child who weighs 4 kg needs 20 oz of standard formula per day [4 kg X 100/20 = 20]).
A history of how formula is prepared for infants is very important. Improperly prepared formula can result in failure to thrive and serious electrolyte imbalances. A recent study examined growth in preterm infants fed preterm formula or standard term formula after discharge.2 If solid foods are being consumed, a careful history of the type of food, meal frequency, and volume per feeding all may be helpful in determining whether a child is receiving enough energy intake. If history is difficult to obtain, a food diary of up to 3 days may be requested from the parents. Although nutritionists are helpful in calculating the exact number of calories consumed by each child, pediatricians may obtain an accurate view of the child's intake by using diaries.
In breastfed infants and formula-fed infants, the frequency of feeds, number of wet diapers and stools each day, and a history of sequential weights allow the physician the ability to gauge if the child is receiving adequate amounts of fluid and calories and is gaining weight appropriately.
In addition to obtaining specific history about method and efficacy of feeding, gathering any information about the bowel habits of a child being evaluated for failure to thrive is important. Babies with chronic diarrhea may fail to grow properly.
Parents also should be asked about any illnesses that occurred since the neonatal period. Particularly serious infections, such as meningitis, may have deleterious effects on the growth potential of children. Also, any history of signs of chronic conditions, such as cerebral palsy (CP), spasticity, seizures, and delayed development, may be important clues when evaluating a child for failure to thrive.
Family and social history should include other siblings, living conditions, stressors, and data on parents' growth history.
Physical
The first thing that pediatricians should do in all health assessments is to plot the head circumference, height, and weight on a growth chart. Insisting on careful measurements during each examination is important. Every effort should be made to obtain as many previous growth parameters as possible to detect trends in growth rather than to rely on measurements at one particular visit.
Growth charts should be evaluated for the pattern of failure to thrive. If weight, height, and head circumference are all less than what is expected for age, this may result from in utero insults or genetic or chromosomal factors (see Media file 1).3
Failure of growth in weight, length, and head circumference starting at birth, suggesting an organic etiology that occurred in utero.
If weight and height growth are delayed with a normal head circumference, endocrinopathies (Media files 2-3) or constitutional delay (Media file 4) should be suspected.
Growth failure in length and weight with a normal head circumference in an infant with growth hormone deficiency.
Acquired hypothyroidism.
Constitutional delay of growth.
This pattern also can occur in long-standing failure to thrive. Ultimately head circumference is delayed, emphasizing the importance of following these growth parameters over time. When only weight gain is delayed, this usually reflects recent energy (caloric) deprivation (see Media file 5).
Failure to thrive secondary to caloric deprivation.
Vital signs are usually within the reference range, but documenting the following vital signs is important:
Blood pressure
Respiration
Pulse rate
Oxygen saturation in certain clinical situations
The physical examination of children with failure to thrive may show the following:
Edema
Wasting
Hepatomegaly4
Rash or skin changes
Hair color and texture changes
Mental status changes
Signs of vitamin deficiency
Marasmus (caused by insufficient caloric intake) must be distinguished from dehydration, which is characterized by the following signs:
Decreased skin turgor
Depressed sensorium
Sunken anterior fontanelle
Dry mucous membranes
Absence of tears
Acutely ill appearance
Causes
Different classification systems have been developed to identify the reasons for failure to thrive in children. Three categories into which all failure to thrive can be classified are nonorganic failure to thrive, organic failure to thrive, and a combination of nonorganic and organic failure to thrive.5
Nonorganic failure to thrive
Nonorganic failure to thrive usually results from various environmental and psychosocial factors. It is often associated with abnormal interactions between the caregiver and the infant or child. This can result in an inadequate provision of food and/or inadequate intake of food. Nonorganic failure to thrive can begin prenatally or occur postnatally.6
Prenatal causes of nonorganic failure to thrive: Mothers who are malnourished often have babies who are malnourished and small. Some evidence suggests that, if mothers do not bond with their unborn babies, those babies undergo failure to thrive in utero as well. Lower birth weights are also associated with teen pregnancies, lower socioeconomic level, and multiple gestations. Maternal eating disorders (eg, anorexia, bulimia) certainly can affect the growth of fetuses as well.
Postnatal causes of nonorganic failure to thrive
Traditionally, nonorganic postnatal causes of failure to thrive were thought to be due to maternal rejection or neglect. In 1985, Skuse suggested that clinicians inquire about more than just the nutrition offered to children.7 He found behavior at meals and psychosocial issues to be important variables affecting whether children obtain sufficient energy. Poor parenting and family dysfunction can negatively affect a child's energy intake. Families characterized by less adaptive relationships, higher levels of family conflict, and less emotional support for the mother have an increased percentage of children with failure to thrive. The term psychosocial deprivation was created for these types of situations.
Other nonorganic reasons for failure to thrive in younger children may be a failure to signal hunger, a poor suck, difficulty in weaning, or a refusal to eat; in older children, eating disorders, including anorexia and bulimia, may lead to severe growth disturbances.
Nonorganic causes of failure to thrive are summarized as follows:
Poor feeding or feeding-skills disorder
Dysfunctional family interactions
Difficult parent-child interactions
Lack of support (eg, no friends, no extended family)
Lack of preparation for parenting
Family dysfunction (eg, divorce, spouse abuse, chaotic family style)
Difficult child
Child neglect
Emotional deprivation syndrome
Feeding disorders (eg, anorexia, bulimia)
Organic failure to thrive
Similar to the nonorganic reasons for failure to thrive, organic reasons may also be noted prenatally or postnatally.
Prenatal onset of failure to thrive
Prenatal causes of failure to thrive are often associated with complications of prematurity. Premature babies have increased incidences of almost all medical conditions, including renal disease, heart disease, lung disease, and CNS disorders. All these disorders can lead to intrauterine failure to thrive.
When babies are born prematurely and have associated intrauterine growth retardation (IUGR), they are more likely to have failure to thrive and decreased growth potential. Most premature babies catch-up to the growth of term babies by the time they are aged 2-4 years. However, some premature babies, particularly those with concomitant IUGR, never catch up in their growth.
Whether babies are small because of prematurity or whether they have decreased growth potential and fall into the failure to thrive category sometimes is unclear. A clue to this diagnostic dilemma is that, if infants double their birth weight by age 4 months and triple their birth weight by age 1 year, full catch-up growth can be anticipated.
Other causes of the prenatal onset of failure to thrive include exposure to toxins, environmental influences, maternal factors, intrauterine infection, and placental or chromosomal abnormalities.
Examples of toxins affecting growth are tobacco use in pregnancy, which is known to produce placental insufficiency, and alcohol ingestion during pregnancy. Prenatal ingestion of drugs of abuse, such as cocaine and amphetamines, also can play a role in the prenatal onset of failure to thrive. Because these drugs often are taken together, separating the effects of each drug may be difficult. Also, maternal exposure to medications, such as hydantoin and phenobarbital, can lead to in utero failure to thrive. In addition, maternal illness, such as hypertension, preeclampsia, heart disease, anemia, and advanced diabetes mellitus, can lead to uteroplacental insufficiency and, therefore, result in smaller babies. Another example of prenatal failure to thrive is demonstrated by children affected by chromosomal abnormalities.
Genetic short stature and constitutional delay of growth are 2 conditions associated with decreased growth that need to be distinguished from failure to thrive. From birth to about age 2 years, a baby's weight changes to follow the genetic predisposition of the parents' height and weight. During this time of transition, children with genetic short stature may cross percentiles downward and still be considered normal. However, most children in this category find their true growth curve by age 3 years. Although children with genetic short stature often are below the third percentile on the growth chart, they have normal weight-to-height ratios and bone ages equal to their chronological ages.
The other condition associated with short stature that must be distinguished from failure to thrive is constitutional delay of growth, another variation of normal growth. Children with short stature resulting from constitutional delay often have a family history of delayed growth and puberty. They have a deceleration of growth in the first 2 years that can be confused with failure to thrive, but then grow parallel to but below the third percentile. Puberty is delayed, but ultimate height may be normal. A distinguishing point from genetic short stature is that bone age is delayed.
Postnatal causes of organic failure to thrive
Although differential diagnosis of the category of postnatal causes of organic failure to thrive is vast, it can be subclassified into the following 3 general areas: inadequate energy intake, poor absorption and/or the inability to use absorbed nutrients, and increased metabolic demands.
Causes of inadequate energy intake can result from mechanical problems, craniofacial abnormalities, lack of appetite, breathing difficulties, metabolic problems, and excessive vomiting. Mechanical problems result from a poor suck or swallow secondary to hypotonia or Prader-Willi syndrome or from a neuromuscular or CNS system disease leading to incoordination of this process. Craniofacial abnormalities also are commonly associated with inadequate energy intake and, therefore, cause failure to thrive. For instance, severe micrognathia makes eating difficult, as does cleft lip and cleft palate.
Some children simply have unexplained poor appetites that are unrelated to mechanical problems or structural abnormalities. An example of a cause of inadequate intake is the breathing difficulties that can result from congestive heart failure (CHF) or chronic lung disease (eg, bronchopulmonary dysplasia [BPD]); any difficulty in breathing makes eating more difficult and can result in failure to thrive. Inadequate intake also can result from metabolic abnormalities, excessive vomiting caused by CNS disease, GI tract obstruction, or renal causes. Also, pathological gastroesophageal reflux causing esophagitis may lead to regurgitation of formula or refusal of feeding.
Even when energy intake is adequate, failure to thrive can occur because of poor absorption of food, inability of the body to use absorbed nutrients, or increased loss of nutrients. For example, children with cystic fibrosis (CF) lack pancreatic enzymes that are required for absorption of nutrients. Unless supplemented with exogenous enzymes, children with this condition have failure to thrive from the inadequate use of ingested food. Another example of the inability to use absorbed nutrients is observed in children with celiac disease who have decreased nutrient absorption caused by villous atrophy.
Illnesses that increase metabolic demands, such as hyperthyroidism, also can cause failure to thrive. Some illnesses are characterized by both inadequate intake and increased metabolic demands. For instance, children who have congenital heart disease with CHF and children with BPD have both decreased intake of nutrients and increased metabolic demands. Other medical conditions, such as hyperthyroidism, are associated with failure to thrive based primarily on increased metabolic demands.
Examples of increased loss of nutrients occur with milk protein allergy or other conditions that can be associated with protein-losing enteropathies. Celiac disease has been more recognized in recent years with the introduction of noninvasive tests and should be considered in children with failure to thrive. The prevalence of celiac disease is 1:100 in some studies.
Whether failure to thrive occurs for any of the above reasons alone or a combination of reasons, an important part of the evaluation of all children is observation of the infant while feeding. Observing infants while they are feeding sheds light on maternal-infant interactions, the infant's ability to suck and swallow, and on the fatigability of the child.
Table 1. Summary of Organic Causes of Failure to Thrive
Prenatal causes Prematurity with complications
Maternal malnutrition
Toxic exposure in utero
Alcohol, smoking, medications, infections
IUGR
Chromosomal abnormalities
Postnatal causes Inadequate intake
Lack of appetite (eg, iron deficiency anemia, CNS pathology, chronic infection)
Inability to suck or swallow: CNS or muscular
Vomiting (eg, CNS, metabolic, obstruction, renal)
Gastroesophageal reflux and esophagitis
Poor absorption and/or use of nutrients
GI disorder (eg, CF, celiac disease, Shwachman-Diamond syndrome, chronic diarrhea)
Renal - Renal failure, renal tubular acidosis
Endocrine - Hypothyroidism, diabetes mellitus, growth hormone deficiency
Inborn error of metabolism
Chronic infection (eg, HIV, tuberculosis, parasites)
Increased metabolic demand
Hyperthyroidism
Chronic disease (eg, heart failure, BPD)
Chronic inflammatory conditions (eg, inflammatory bowel disease,
systemic lupus erythematosus)
Renal failure
Malignancy
Combined organic and nonorganic failure to thrive
Failure to thrive in a patient can result from the combination of both organic and nonorganic reasons. In one study, half of the cases with organic etiology had a psychosocial factor contributing to the failure to thrive. This is caused by a number of reasons. It is clear that illnesses in children, particularly chronic illnesses, can take their toll on families. Stresses from coping with chronic illnesses may lead to parental dysfunction, such as depression, alcohol or drug abuse, divorce, or chaotic home environments. Parental dysfunction and the resultant negative atmosphere in which children are reared affect their food intake. In addition, children may undergo personality changes when they have chronic diseases. Medications (eg, steroids) are well known to cause behavioral changes, but the mere presence of a chronic illness also can result in resistance or noncompliance in many aspects of a child's life, including consumption of proper energy intake.
Many examples of children having both organic and nonorganic causes of failure to thrive exist. For example, children with CF, asthma, heart disease, and CP all have organic reasons for failure to thrive. In addition, the social pressures that children with these conditions experience can cause behavioral changes that result in decreased energy intake and, therefore, failure to thrive.
Differential Diagnoses
Child Abuse & Neglect: Failure to Thrive
Constitutional Growth Delay
Eating Disorder: Anorexia
Eating Disorder: Bulimia
Fetal Alcohol Syndrome
Other Problems to Be Considered
Isolated growth hormone deficiency
Other causes for intrauterine growth retardation (IUGR)
Other chromosomal/genetic causes of delayed growth
Workup
Laboratory Studies
If a diagnosis can be made and a cause for failure to thrive (FTT) can be identified, the history and physical examination usually supply the answer. Laboratory assessment has a limited value in determining the etiology of failure to thrive. Occasionally, laboratory test results are unexpectedly abnormal. For instance, blood dyscrasias, chronic urinary tract infections, chronic acidosis, and renal failure all can be diagnosed using these screening tests. However, only about 1% of the tests ordered produce abnormal results and help identify the etiology of failure to thrive.
Children diagnosed with failure to thrive usually undergo certain screening tests, including the following:
CBC count
Urinalysis
Urine culture
Electrolytes, including creatinine and BUN
Liver function tests, including total protein and albumin
Prealbumin may be used as a nutritional marker.
More specific tests may be indicated (depending on findings from the history and physical examination), including the following:
Human immunodeficiency virus (HIV) testing
Sweat chloride test
Thyroid function tests
Stool studies for parasites or malabsorption
Immunoglobulins
Purified protein derivative (PPD) skin test
Radiological studies
If concern surrounds possible growth hormone deficiency, the following may be obtained:
Serum insulinlike growth factor I (IGF-I)
Insulinlike growth factor binding protein (IGF-BP3)
Serum immunoglobulin A tissue transglutaminase antibody (TTG-IgA), IgA-endomysial antibody (IgA-EMA), and immunoglobulin G antigliadin antibodies (AGA-IgG) may be used to screen for celiac disease when clinically indicated.
Imaging Studies
A bone age may be helpful to distinguish genetic short stature from constitutional delay of growth.
Procedures
Other diagnostic procedures may be appropriate and are performed as indicated.
Treatment
Medical Care
Most children with failure to thrive (FTT) can be treated as outpatients; home visits and close clinical follow-ups often help determine the underlying reason for the failure to thrive. However, hospitalization sometimes is necessary for diagnostic and therapeutic reasons. Diagnostic benefits of admission may include observation of feeding, parental-child interaction, and dietary habits, as well as the ability to perform specific tests and consult subspecialists.
Therapeutic benefits may result from hospitalization. Acute needs, such as dehydration, infection, anemia, or electrolyte imbalance, can be addressed and managed within the hospital. For instance, intravenous fluids, systemic antibiotic therapy, transfusion, and, possibly, parenteral nutrition often are in-hospital procedures. Of course, if an organic etiology is found for the failure to thrive in a particular child, specific therapy can be initiated during the hospitalization.
Another benefit of hospitalization may be the observation of parent-child interaction. In addition to observation of the feeding techniques of the parents, other interactions can be observed more easily in the hospital. For instance, the degrees to which parents bond, speak, and even interact with their children all can be observed during the hospital stay. If children gain weight easily during a hospitalization, the cause of the failure to thrive is most likely nonorganic.
Consultations
When treating children with failure to thrive, an interdisciplinary team approach combining pediatric, nutritional, mental health, and social work expertise often is helpful. An interdisciplinary approach ensures that programs such as women, infants, and children (WIC); food stamps; and Medicaid can be accessed. Using an interdisciplinary approach is also helpful if appropriate home-based intervention needs to be arranged.
Other advantages of using an interdisciplinary team include the fact that the family's psychosocial situation can be addressed and intervention can be provided. For example, an older child with a chronic illness and failure to thrive may benefit from referral to a psychologist. If neglect is suspected, child protective services can become involved as a result of this multidisciplinary approach.
Subspecialists should be involved for the treatment of organic illness when identified.
Diet
The long-term goal for every child with failure to thrive is to provide adequate energy intake for growth. Therefore, even if no etiology is found for a child with failure to thrive, aggressive dietary management is the cornerstone of therapy. Proper feeding can be achieved through infant formulas that are adjusted to meet the child's specific nutrient needs. For instance, some children are given formulas that have as much as 30 kcal/oz, whereas other children may receive regular 20 kcal/oz formulas supplemented with high-calorie food fortifiers, which can be lipids, protein, or carbohydrates (CHO).
Infants may be given concentrated formulas, assuming renal function is normal. If this option is chosen, renal function must be normal because the osmolar load of the resultant formula is high. In cases in which this is a problem because of renal insufficiency, increasing the fat content of the formula may be useful as a way of delivering additional calories.
Supplements for older children may include adding cheese, sour cream, butter, margarine, or peanut butter to meals. Also, high-energy (approximately 1 kcal/mL) shakes, which are available in different flavors, provide a good supplement (eg, Pedia Sure, Kindercal, Boost). Multivitamin and mineral supplements, including iron and zinc, usually are recommended to all undernourished children. Tube feeding rarely is indicated except for severe malnutrition and debilitation. In children with organic failure to thrive, continuous nighttime tube feeding also may be used to increase their energy intake.
Whether the child with failure to thrive is an inpatient or an outpatient, increasing energy intake is necessary. In younger children, energy intake is increased by increasing the amount of formula or caloric concentration of formula, using 24 or 27 kcal/oz, or adding calorie fortifiers. In toddlers, supplemental high-energy formulas as much as 30 kcal/oz are used. Sometimes these can be administered through tube feedings.
Table 2. Examples of High-Calorie FortifiersProduct Calories Source
Medium-chain triglyceride (MCT) oil 7.7 kcal/mL Fractionated coconut oil
Microlipid 4.5 kcal/mL Safflower oil
Corn oil 8.4 kcal/mL Corn
ProMod (protein powder) 28 kcal/scoop (4.2 kcal/g)
5 g/scoop Whey protein with lecithin
Polycose (powder or liquid) Powder - 23 kcal/tbsp
Liquid - 30 kcal/tbsp Powder - Hydrolyzed cornstarch
Liquid - Glucose polymers derived from hydrolyzed cornstarch
Rice cereal (powder) 15 kcal/tbsp Rice flour
Nonfat dry milk powder 15 kcal/T (1.5 g protein) Cow's milk
Powder infant formula 40 kcal/tbsp Cow's milk
Liquid concentrated infant formula 40 kcal/oz Cow's milk
Table 3. Examples of High-Calorie Nutritional ProductsProduct, 30 kcal/oz CHO, g/100 mL Protein, g/100 mL Fat, g/100 mL Osmolality Nutrient Sources
Nutren Junior
(Clintec) 12.8 3 4.2 350 CHO - Maltodextrin, sucrose
Protein - Casein, whey
Fat - Soy, MCT, and canola oils
(Vanilla, also available with fiber)
Kindercal
(Mead Johnson) 13.5 3.4 4.4 310 CHO - Maltodextrin, sucrose
Protein - Caseinates, milk protein concentrate
Fat - Canola, MCT, and high-oleic sunflower oils
Contains soy fiber 6.3 g/L
(Vanilla)
PediaSure
(Ross) 11 3 5 310 CHO - Corn syrup solids, sucrose
Protein - Caseinate, whey protein concentrate
Fat - High-oleic safflower, soy, and MCT oils
(Vanilla, also available with fiber)
Boost
(Mead Johnson) 17.4 4.3 1.7 590-620 CHO - Sucrose, corn syrup solids
Protein - Milk protein concentrate
Fat - Canola, sunflower, corn oils
(Chocolate, chocolate mocha, strawberry, vanilla)
Follow-up
Further Outpatient Care
Children with failure to thrive (FTT) need continued follow-up care to observe their growth parameters using the appropriate growth charts.
Prognosis
Clearly, the ultimate physical growth may be slowed in children with failure to thrive (FTT) syndrome (see Mortality/Morbidity). Traditionally, nonorganic causes of failure to thrive have been thought to result in more cognitive deficits than found with organic causes. In addition, whether early intervention or home visits can affect development positively is unclear. In 1995, Black demonstrated that home intervention may reduce developmental delays, mainly cognitive delays in young children.8 In 1999, Raynor demonstrated that, although children who received home visits had less dietary referrals, social services involvement, and hospital admissions, no effect on growth was observed.9
Failure to thrive remains one of the greatest challenges for the practicing pediatrician. The process of the attempt at identification of the causes can be exhausting and expensive. The list of organic and nonorganic causes of this entity is extensive, and combinations of the 2 types of causes are common in specific children. Failure to thrive can have its roots in prenatal origins or can develop postnatally. Information from a careful extensive history and from a detailed physical examination may give important clues to the underlying diagnoses. Hospitalization and the involvement of a multispecialty team may be helpful in diagnosis.
Whether failure to thrive results from organic or nonorganic reasons, children with this condition require aggressive calorie supplementation; examples of the sources of such calories are summarized in Tables 2-3 of this article. The cognitive outcome of children who have had failure to thrive is not clear. However, a careful and timely search for the causes of failure to thrive and implementation of aggressive calorie supplementation is important in obtaining the best possible outcome in these children.
Patient Education
For excellent patient education resources, visit eMedicine's Growth Hormone Deficiency Center. Also, see eMedicine's patient education articles Growth Failure in Children, Growth Hormone Deficiency, Growth Hormone Deficiency in Children, and Growth Hormone Deficiency FAQs
http://emedicine.medscape.com/article/985007-print
Mohammad F El-Baba, MD, Assistant Professor of Pediatrics, Division of Pediatric Gastroenterology, Wayne State University School of Medicine; Division Chief of Pediatric Gastroenterology, Children's Hospital of Michigan
Reda W Bassali, MBChB, Associate Professor, Departments of General Pediatrics and Adolescent Medicine, Medical College of Georgia; John Benjamin, MD, Chief, General Section of Pediatrics and Adolescent Medicine, Vice Chair for Clinical Activities, Professor, Department of General Pediatrics, Medical College of Georgia; Ruby Mehta, MD, Fellow, Division of Pediatric Gastroenterology, Children's Hospital of Michigan
Updated: May 4, 2009
Introduction
Background
Growth failure, or failure to thrive (FTT), is a descriptive term and not a specific diagnosis. This term is widely used to describe inadequate growth in early childhood. However, no consensus has been reached concerning the specific anthropometrical criteria to define this description. Although definitions vary, most authors use this term only when growth has been noted to be low or to have decreased over time. For instance, some authors define failure to thrive as height or weight less than the third to fifth percentiles for age on more than one occasion. Other authors cite height or weight measurements falling 2 major percentile lines using the standard growth charts of the National Center for Health Statistics (NCHS). Still others state that true malnutrition (weight <80% of ideal body weight for age) should be present to state a child is failing to thrive.
All authorities agree that only by comparing height and weight on a growth chart over time can failure to thrive be accurately assessed. Although measurements of head circumference are important in the evaluation of infants and toddlers, failure of the head to grow by itself is not part of the failure to thrive entity.1
Normal growth and growth charts of term and premature infants, as well as the etiology, evaluation, management, and outcome of failure to thrive are discussed in this article.
Pathophysiology
Normal growth in term infants
To recognize abnormal growth, one needs to understand normal growth. The average birth weight for a term infant is 3.3 kg. Weight drops as much as 10% in the first few days of life, probably as a result of loss of excess fluid; however, birth weight should be regained within 2 weeks after birth. Breastfed infants tend to regain birth weight a little later than bottle-fed infants.
The median increase in weight per day in children is summarized below. On average, infants gain 1 kg/mo for the first 3 months, 0.5 kg/mo from age 3-6 months, 0.33 kg/mo from age 6-9 months, and 0.25 kg/mo from age 9-12 months. Term infants double their birth weight by age 4 months and triple their weight by age 12 months.
Median daily weight gain by age groups is as follows:
0-3 months - 26-31 g
3-6 months - 17-18 g
6-9 months - 12-13 g
9-12 months - 9 g
1-3 years - 7-9 g
4-6 years - 6 g
Term infants grow 25 cm in length during the first year, 12.5 cm in the second year, and then slow down to approximately 5-6 cm between age 4 years and the onset of puberty, at which time growth can increase up to 12 cm per year.
The average head circumference is 35 cm at birth and increases rapidly to 47 cm by age 1 year; the rate of growth then slows, reaching an average of 55 cm by age 6 years.
Also, the upper-to-lower body segment ratio changes with growth. Normally, the ratio at birth is 1.7, the ratio at age 3 years is 1.3, and the ratio by age 7 years becomes 1.0. The lower body segment is the measurement of the symphysis pubis to the floor.
Normal growth in premature infants
When plotting growth charts for premature babies, a "corrected age" should be used. This corrected age can be calculated by subtracting the number of weeks of prematurity from the postnatal age. Special growth charts based on gestational age rather than chronological age have been developed for infants, beginning at 26 weeks' gestational age; however, because these charts represent a compilation of a relatively small number of infants, they may not be completely reliable. Whichever technique is used for premature babies (eg, adjustment of age, using specific premature growth charts), consistency of methodology is essential. Once a method for plotting growth is chosen, that technique should be followed each time plotting occurs.
After catch-up growth is attained, at approximately age 18 months for head circumference, age 24 months for weight, and age 40 months for height, normal growth charts can be used. In some premature babies with very low birth-weight, catch-up growth does not occur until early school age.
Growth charts
Growth charts were developed by the National Center for Health Statistics based on data collected through the Third National Health and Nutrition Examination Survey III. The growth charts, which have been used since 1977, are available for males and females aged 0-36 months and aged 2-18 years. The growth charts for boys and girls aged 0-36 months include weight and height for age and head circumference; growth charts for both age groups include weight for stature.
These charts have been revised and are available from the Centers for Disease Control and Prevention (2000 CDC Growth Charts: United States). The new charts are applicable to infants, children, and adolescents from birth to age 20 years and have 7 percentile curves (5th, 10th, 25th, 50th, 75th, 90th, 95th). Charts are available for use in subspecialty patients (eg, endocrine, gastroenterology) with additional third and 97th percentile curves.
Body mass index (BMI) charts, which are available for individuals aged 2-20 years, have replaced the weight-for-stature charts. BMI is calculated by dividing weight in kilograms by height in meters squared.
Accurate measurements are essential to the interpretation of growth charts. Scales need to be calibrated regularly; length should be measured carefully, and head circumference should be measured using standardized techniques.
Alternate growth charts are available for children with Down syndrome, Turner syndrome, meningomyelocele, low birth weight, and very low birth weight. No matter which growth chart is used, the most valuable information is obtained by careful measuring and plotting on the same chart over time. Infants and children remain within 1-2 percentile curves over time.
Frequency
United States
In reports from 1980-1989, failure to thrive accounted for 1-5% of tertiary hospital admissions for infants younger than 1 year. An estimated 10% of children in primary care settings show signs of failure to thrive.
International
In underdeveloped countries, malnutrition manifesting as failure to thrive is more common.
Mortality/Morbidity
Ultimate physical growth may be decreased in children with failure to thrive. Cognitive development is affected in children younger than 5 years who have failure to thrive. With improvement of nutritional status, these deficits may not be completely reversed. Traditionally, it has been thought that nonorganic causes of failure to thrive resulted in more cognitive deficits than are observed with organic causes. In developing countries, malnutrition is a significant cause of mortality, whether directly or secondary to complications (eg, infection).
Race
Failure to thrive can occur in all socioeconomic strata, although it is more frequent in families living in poverty. Studies indicate increased incidence in children receiving Medicaid, children living in rural areas, and children who are homeless.
Sex
Nonorganic failure to thrive is reported more commonly in females than in males.
Clinical
History
The most important part of the evaluation of children with failure to thrive (FTT) may be obtaining a careful detailed history. Once failure to thrive is identified in a particular child, an attempt then should be made to determine from the history whether nonorganic failure to thrive, organic failure to thrive, or a combination of the 2 is present. Prenatal history is extremely important and information regarding the following should be obtained:
Smoking
Alcohol consumption
Use of medications
Any illness during the pregnancy
Similarly, a history of any problems in the nursery should be obtained. Dietary history provides very important information. A simple formula for bottle-feeding infants to determine the proper number of ounces they should consume in 24 hours is to multiply the weight in kilograms by 5. (Calculation is reached by assuming that children need 100 kcal/kg and that each ounce of standard formula contains 20 kcal/oz; thus, for each kilogram of a child's weight, 5 [ie, 100 divided by 20] ounces are needed for proper growth and weight gain. For example, a child who weighs 4 kg needs 20 oz of standard formula per day [4 kg X 100/20 = 20]).
A history of how formula is prepared for infants is very important. Improperly prepared formula can result in failure to thrive and serious electrolyte imbalances. A recent study examined growth in preterm infants fed preterm formula or standard term formula after discharge.2 If solid foods are being consumed, a careful history of the type of food, meal frequency, and volume per feeding all may be helpful in determining whether a child is receiving enough energy intake. If history is difficult to obtain, a food diary of up to 3 days may be requested from the parents. Although nutritionists are helpful in calculating the exact number of calories consumed by each child, pediatricians may obtain an accurate view of the child's intake by using diaries.
In breastfed infants and formula-fed infants, the frequency of feeds, number of wet diapers and stools each day, and a history of sequential weights allow the physician the ability to gauge if the child is receiving adequate amounts of fluid and calories and is gaining weight appropriately.
In addition to obtaining specific history about method and efficacy of feeding, gathering any information about the bowel habits of a child being evaluated for failure to thrive is important. Babies with chronic diarrhea may fail to grow properly.
Parents also should be asked about any illnesses that occurred since the neonatal period. Particularly serious infections, such as meningitis, may have deleterious effects on the growth potential of children. Also, any history of signs of chronic conditions, such as cerebral palsy (CP), spasticity, seizures, and delayed development, may be important clues when evaluating a child for failure to thrive.
Family and social history should include other siblings, living conditions, stressors, and data on parents' growth history.
Physical
The first thing that pediatricians should do in all health assessments is to plot the head circumference, height, and weight on a growth chart. Insisting on careful measurements during each examination is important. Every effort should be made to obtain as many previous growth parameters as possible to detect trends in growth rather than to rely on measurements at one particular visit.
Growth charts should be evaluated for the pattern of failure to thrive. If weight, height, and head circumference are all less than what is expected for age, this may result from in utero insults or genetic or chromosomal factors (see Media file 1).3
Failure of growth in weight, length, and head circumference starting at birth, suggesting an organic etiology that occurred in utero.
If weight and height growth are delayed with a normal head circumference, endocrinopathies (Media files 2-3) or constitutional delay (Media file 4) should be suspected.
Growth failure in length and weight with a normal head circumference in an infant with growth hormone deficiency.
Acquired hypothyroidism.
Constitutional delay of growth.
This pattern also can occur in long-standing failure to thrive. Ultimately head circumference is delayed, emphasizing the importance of following these growth parameters over time. When only weight gain is delayed, this usually reflects recent energy (caloric) deprivation (see Media file 5).
Failure to thrive secondary to caloric deprivation.
Vital signs are usually within the reference range, but documenting the following vital signs is important:
Blood pressure
Respiration
Pulse rate
Oxygen saturation in certain clinical situations
The physical examination of children with failure to thrive may show the following:
Edema
Wasting
Hepatomegaly4
Rash or skin changes
Hair color and texture changes
Mental status changes
Signs of vitamin deficiency
Marasmus (caused by insufficient caloric intake) must be distinguished from dehydration, which is characterized by the following signs:
Decreased skin turgor
Depressed sensorium
Sunken anterior fontanelle
Dry mucous membranes
Absence of tears
Acutely ill appearance
Causes
Different classification systems have been developed to identify the reasons for failure to thrive in children. Three categories into which all failure to thrive can be classified are nonorganic failure to thrive, organic failure to thrive, and a combination of nonorganic and organic failure to thrive.5
Nonorganic failure to thrive
Nonorganic failure to thrive usually results from various environmental and psychosocial factors. It is often associated with abnormal interactions between the caregiver and the infant or child. This can result in an inadequate provision of food and/or inadequate intake of food. Nonorganic failure to thrive can begin prenatally or occur postnatally.6
Prenatal causes of nonorganic failure to thrive: Mothers who are malnourished often have babies who are malnourished and small. Some evidence suggests that, if mothers do not bond with their unborn babies, those babies undergo failure to thrive in utero as well. Lower birth weights are also associated with teen pregnancies, lower socioeconomic level, and multiple gestations. Maternal eating disorders (eg, anorexia, bulimia) certainly can affect the growth of fetuses as well.
Postnatal causes of nonorganic failure to thrive
Traditionally, nonorganic postnatal causes of failure to thrive were thought to be due to maternal rejection or neglect. In 1985, Skuse suggested that clinicians inquire about more than just the nutrition offered to children.7 He found behavior at meals and psychosocial issues to be important variables affecting whether children obtain sufficient energy. Poor parenting and family dysfunction can negatively affect a child's energy intake. Families characterized by less adaptive relationships, higher levels of family conflict, and less emotional support for the mother have an increased percentage of children with failure to thrive. The term psychosocial deprivation was created for these types of situations.
Other nonorganic reasons for failure to thrive in younger children may be a failure to signal hunger, a poor suck, difficulty in weaning, or a refusal to eat; in older children, eating disorders, including anorexia and bulimia, may lead to severe growth disturbances.
Nonorganic causes of failure to thrive are summarized as follows:
Poor feeding or feeding-skills disorder
Dysfunctional family interactions
Difficult parent-child interactions
Lack of support (eg, no friends, no extended family)
Lack of preparation for parenting
Family dysfunction (eg, divorce, spouse abuse, chaotic family style)
Difficult child
Child neglect
Emotional deprivation syndrome
Feeding disorders (eg, anorexia, bulimia)
Organic failure to thrive
Similar to the nonorganic reasons for failure to thrive, organic reasons may also be noted prenatally or postnatally.
Prenatal onset of failure to thrive
Prenatal causes of failure to thrive are often associated with complications of prematurity. Premature babies have increased incidences of almost all medical conditions, including renal disease, heart disease, lung disease, and CNS disorders. All these disorders can lead to intrauterine failure to thrive.
When babies are born prematurely and have associated intrauterine growth retardation (IUGR), they are more likely to have failure to thrive and decreased growth potential. Most premature babies catch-up to the growth of term babies by the time they are aged 2-4 years. However, some premature babies, particularly those with concomitant IUGR, never catch up in their growth.
Whether babies are small because of prematurity or whether they have decreased growth potential and fall into the failure to thrive category sometimes is unclear. A clue to this diagnostic dilemma is that, if infants double their birth weight by age 4 months and triple their birth weight by age 1 year, full catch-up growth can be anticipated.
Other causes of the prenatal onset of failure to thrive include exposure to toxins, environmental influences, maternal factors, intrauterine infection, and placental or chromosomal abnormalities.
Examples of toxins affecting growth are tobacco use in pregnancy, which is known to produce placental insufficiency, and alcohol ingestion during pregnancy. Prenatal ingestion of drugs of abuse, such as cocaine and amphetamines, also can play a role in the prenatal onset of failure to thrive. Because these drugs often are taken together, separating the effects of each drug may be difficult. Also, maternal exposure to medications, such as hydantoin and phenobarbital, can lead to in utero failure to thrive. In addition, maternal illness, such as hypertension, preeclampsia, heart disease, anemia, and advanced diabetes mellitus, can lead to uteroplacental insufficiency and, therefore, result in smaller babies. Another example of prenatal failure to thrive is demonstrated by children affected by chromosomal abnormalities.
Genetic short stature and constitutional delay of growth are 2 conditions associated with decreased growth that need to be distinguished from failure to thrive. From birth to about age 2 years, a baby's weight changes to follow the genetic predisposition of the parents' height and weight. During this time of transition, children with genetic short stature may cross percentiles downward and still be considered normal. However, most children in this category find their true growth curve by age 3 years. Although children with genetic short stature often are below the third percentile on the growth chart, they have normal weight-to-height ratios and bone ages equal to their chronological ages.
The other condition associated with short stature that must be distinguished from failure to thrive is constitutional delay of growth, another variation of normal growth. Children with short stature resulting from constitutional delay often have a family history of delayed growth and puberty. They have a deceleration of growth in the first 2 years that can be confused with failure to thrive, but then grow parallel to but below the third percentile. Puberty is delayed, but ultimate height may be normal. A distinguishing point from genetic short stature is that bone age is delayed.
Postnatal causes of organic failure to thrive
Although differential diagnosis of the category of postnatal causes of organic failure to thrive is vast, it can be subclassified into the following 3 general areas: inadequate energy intake, poor absorption and/or the inability to use absorbed nutrients, and increased metabolic demands.
Causes of inadequate energy intake can result from mechanical problems, craniofacial abnormalities, lack of appetite, breathing difficulties, metabolic problems, and excessive vomiting. Mechanical problems result from a poor suck or swallow secondary to hypotonia or Prader-Willi syndrome or from a neuromuscular or CNS system disease leading to incoordination of this process. Craniofacial abnormalities also are commonly associated with inadequate energy intake and, therefore, cause failure to thrive. For instance, severe micrognathia makes eating difficult, as does cleft lip and cleft palate.
Some children simply have unexplained poor appetites that are unrelated to mechanical problems or structural abnormalities. An example of a cause of inadequate intake is the breathing difficulties that can result from congestive heart failure (CHF) or chronic lung disease (eg, bronchopulmonary dysplasia [BPD]); any difficulty in breathing makes eating more difficult and can result in failure to thrive. Inadequate intake also can result from metabolic abnormalities, excessive vomiting caused by CNS disease, GI tract obstruction, or renal causes. Also, pathological gastroesophageal reflux causing esophagitis may lead to regurgitation of formula or refusal of feeding.
Even when energy intake is adequate, failure to thrive can occur because of poor absorption of food, inability of the body to use absorbed nutrients, or increased loss of nutrients. For example, children with cystic fibrosis (CF) lack pancreatic enzymes that are required for absorption of nutrients. Unless supplemented with exogenous enzymes, children with this condition have failure to thrive from the inadequate use of ingested food. Another example of the inability to use absorbed nutrients is observed in children with celiac disease who have decreased nutrient absorption caused by villous atrophy.
Illnesses that increase metabolic demands, such as hyperthyroidism, also can cause failure to thrive. Some illnesses are characterized by both inadequate intake and increased metabolic demands. For instance, children who have congenital heart disease with CHF and children with BPD have both decreased intake of nutrients and increased metabolic demands. Other medical conditions, such as hyperthyroidism, are associated with failure to thrive based primarily on increased metabolic demands.
Examples of increased loss of nutrients occur with milk protein allergy or other conditions that can be associated with protein-losing enteropathies. Celiac disease has been more recognized in recent years with the introduction of noninvasive tests and should be considered in children with failure to thrive. The prevalence of celiac disease is 1:100 in some studies.
Whether failure to thrive occurs for any of the above reasons alone or a combination of reasons, an important part of the evaluation of all children is observation of the infant while feeding. Observing infants while they are feeding sheds light on maternal-infant interactions, the infant's ability to suck and swallow, and on the fatigability of the child.
Table 1. Summary of Organic Causes of Failure to Thrive
Prenatal causes Prematurity with complications
Maternal malnutrition
Toxic exposure in utero
Alcohol, smoking, medications, infections
IUGR
Chromosomal abnormalities
Postnatal causes Inadequate intake
Lack of appetite (eg, iron deficiency anemia, CNS pathology, chronic infection)
Inability to suck or swallow: CNS or muscular
Vomiting (eg, CNS, metabolic, obstruction, renal)
Gastroesophageal reflux and esophagitis
Poor absorption and/or use of nutrients
GI disorder (eg, CF, celiac disease, Shwachman-Diamond syndrome, chronic diarrhea)
Renal - Renal failure, renal tubular acidosis
Endocrine - Hypothyroidism, diabetes mellitus, growth hormone deficiency
Inborn error of metabolism
Chronic infection (eg, HIV, tuberculosis, parasites)
Increased metabolic demand
Hyperthyroidism
Chronic disease (eg, heart failure, BPD)
Chronic inflammatory conditions (eg, inflammatory bowel disease,
systemic lupus erythematosus)
Renal failure
Malignancy
Combined organic and nonorganic failure to thrive
Failure to thrive in a patient can result from the combination of both organic and nonorganic reasons. In one study, half of the cases with organic etiology had a psychosocial factor contributing to the failure to thrive. This is caused by a number of reasons. It is clear that illnesses in children, particularly chronic illnesses, can take their toll on families. Stresses from coping with chronic illnesses may lead to parental dysfunction, such as depression, alcohol or drug abuse, divorce, or chaotic home environments. Parental dysfunction and the resultant negative atmosphere in which children are reared affect their food intake. In addition, children may undergo personality changes when they have chronic diseases. Medications (eg, steroids) are well known to cause behavioral changes, but the mere presence of a chronic illness also can result in resistance or noncompliance in many aspects of a child's life, including consumption of proper energy intake.
Many examples of children having both organic and nonorganic causes of failure to thrive exist. For example, children with CF, asthma, heart disease, and CP all have organic reasons for failure to thrive. In addition, the social pressures that children with these conditions experience can cause behavioral changes that result in decreased energy intake and, therefore, failure to thrive.
Differential Diagnoses
Child Abuse & Neglect: Failure to Thrive
Constitutional Growth Delay
Eating Disorder: Anorexia
Eating Disorder: Bulimia
Fetal Alcohol Syndrome
Other Problems to Be Considered
Isolated growth hormone deficiency
Other causes for intrauterine growth retardation (IUGR)
Other chromosomal/genetic causes of delayed growth
Workup
Laboratory Studies
If a diagnosis can be made and a cause for failure to thrive (FTT) can be identified, the history and physical examination usually supply the answer. Laboratory assessment has a limited value in determining the etiology of failure to thrive. Occasionally, laboratory test results are unexpectedly abnormal. For instance, blood dyscrasias, chronic urinary tract infections, chronic acidosis, and renal failure all can be diagnosed using these screening tests. However, only about 1% of the tests ordered produce abnormal results and help identify the etiology of failure to thrive.
Children diagnosed with failure to thrive usually undergo certain screening tests, including the following:
CBC count
Urinalysis
Urine culture
Electrolytes, including creatinine and BUN
Liver function tests, including total protein and albumin
Prealbumin may be used as a nutritional marker.
More specific tests may be indicated (depending on findings from the history and physical examination), including the following:
Human immunodeficiency virus (HIV) testing
Sweat chloride test
Thyroid function tests
Stool studies for parasites or malabsorption
Immunoglobulins
Purified protein derivative (PPD) skin test
Radiological studies
If concern surrounds possible growth hormone deficiency, the following may be obtained:
Serum insulinlike growth factor I (IGF-I)
Insulinlike growth factor binding protein (IGF-BP3)
Serum immunoglobulin A tissue transglutaminase antibody (TTG-IgA), IgA-endomysial antibody (IgA-EMA), and immunoglobulin G antigliadin antibodies (AGA-IgG) may be used to screen for celiac disease when clinically indicated.
Imaging Studies
A bone age may be helpful to distinguish genetic short stature from constitutional delay of growth.
Procedures
Other diagnostic procedures may be appropriate and are performed as indicated.
Treatment
Medical Care
Most children with failure to thrive (FTT) can be treated as outpatients; home visits and close clinical follow-ups often help determine the underlying reason for the failure to thrive. However, hospitalization sometimes is necessary for diagnostic and therapeutic reasons. Diagnostic benefits of admission may include observation of feeding, parental-child interaction, and dietary habits, as well as the ability to perform specific tests and consult subspecialists.
Therapeutic benefits may result from hospitalization. Acute needs, such as dehydration, infection, anemia, or electrolyte imbalance, can be addressed and managed within the hospital. For instance, intravenous fluids, systemic antibiotic therapy, transfusion, and, possibly, parenteral nutrition often are in-hospital procedures. Of course, if an organic etiology is found for the failure to thrive in a particular child, specific therapy can be initiated during the hospitalization.
Another benefit of hospitalization may be the observation of parent-child interaction. In addition to observation of the feeding techniques of the parents, other interactions can be observed more easily in the hospital. For instance, the degrees to which parents bond, speak, and even interact with their children all can be observed during the hospital stay. If children gain weight easily during a hospitalization, the cause of the failure to thrive is most likely nonorganic.
Consultations
When treating children with failure to thrive, an interdisciplinary team approach combining pediatric, nutritional, mental health, and social work expertise often is helpful. An interdisciplinary approach ensures that programs such as women, infants, and children (WIC); food stamps; and Medicaid can be accessed. Using an interdisciplinary approach is also helpful if appropriate home-based intervention needs to be arranged.
Other advantages of using an interdisciplinary team include the fact that the family's psychosocial situation can be addressed and intervention can be provided. For example, an older child with a chronic illness and failure to thrive may benefit from referral to a psychologist. If neglect is suspected, child protective services can become involved as a result of this multidisciplinary approach.
Subspecialists should be involved for the treatment of organic illness when identified.
Diet
The long-term goal for every child with failure to thrive is to provide adequate energy intake for growth. Therefore, even if no etiology is found for a child with failure to thrive, aggressive dietary management is the cornerstone of therapy. Proper feeding can be achieved through infant formulas that are adjusted to meet the child's specific nutrient needs. For instance, some children are given formulas that have as much as 30 kcal/oz, whereas other children may receive regular 20 kcal/oz formulas supplemented with high-calorie food fortifiers, which can be lipids, protein, or carbohydrates (CHO).
Infants may be given concentrated formulas, assuming renal function is normal. If this option is chosen, renal function must be normal because the osmolar load of the resultant formula is high. In cases in which this is a problem because of renal insufficiency, increasing the fat content of the formula may be useful as a way of delivering additional calories.
Supplements for older children may include adding cheese, sour cream, butter, margarine, or peanut butter to meals. Also, high-energy (approximately 1 kcal/mL) shakes, which are available in different flavors, provide a good supplement (eg, Pedia Sure, Kindercal, Boost). Multivitamin and mineral supplements, including iron and zinc, usually are recommended to all undernourished children. Tube feeding rarely is indicated except for severe malnutrition and debilitation. In children with organic failure to thrive, continuous nighttime tube feeding also may be used to increase their energy intake.
Whether the child with failure to thrive is an inpatient or an outpatient, increasing energy intake is necessary. In younger children, energy intake is increased by increasing the amount of formula or caloric concentration of formula, using 24 or 27 kcal/oz, or adding calorie fortifiers. In toddlers, supplemental high-energy formulas as much as 30 kcal/oz are used. Sometimes these can be administered through tube feedings.
Table 2. Examples of High-Calorie FortifiersProduct Calories Source
Medium-chain triglyceride (MCT) oil 7.7 kcal/mL Fractionated coconut oil
Microlipid 4.5 kcal/mL Safflower oil
Corn oil 8.4 kcal/mL Corn
ProMod (protein powder) 28 kcal/scoop (4.2 kcal/g)
5 g/scoop Whey protein with lecithin
Polycose (powder or liquid) Powder - 23 kcal/tbsp
Liquid - 30 kcal/tbsp Powder - Hydrolyzed cornstarch
Liquid - Glucose polymers derived from hydrolyzed cornstarch
Rice cereal (powder) 15 kcal/tbsp Rice flour
Nonfat dry milk powder 15 kcal/T (1.5 g protein) Cow's milk
Powder infant formula 40 kcal/tbsp Cow's milk
Liquid concentrated infant formula 40 kcal/oz Cow's milk
Table 3. Examples of High-Calorie Nutritional ProductsProduct, 30 kcal/oz CHO, g/100 mL Protein, g/100 mL Fat, g/100 mL Osmolality Nutrient Sources
Nutren Junior
(Clintec) 12.8 3 4.2 350 CHO - Maltodextrin, sucrose
Protein - Casein, whey
Fat - Soy, MCT, and canola oils
(Vanilla, also available with fiber)
Kindercal
(Mead Johnson) 13.5 3.4 4.4 310 CHO - Maltodextrin, sucrose
Protein - Caseinates, milk protein concentrate
Fat - Canola, MCT, and high-oleic sunflower oils
Contains soy fiber 6.3 g/L
(Vanilla)
PediaSure
(Ross) 11 3 5 310 CHO - Corn syrup solids, sucrose
Protein - Caseinate, whey protein concentrate
Fat - High-oleic safflower, soy, and MCT oils
(Vanilla, also available with fiber)
Boost
(Mead Johnson) 17.4 4.3 1.7 590-620 CHO - Sucrose, corn syrup solids
Protein - Milk protein concentrate
Fat - Canola, sunflower, corn oils
(Chocolate, chocolate mocha, strawberry, vanilla)
Follow-up
Further Outpatient Care
Children with failure to thrive (FTT) need continued follow-up care to observe their growth parameters using the appropriate growth charts.
Prognosis
Clearly, the ultimate physical growth may be slowed in children with failure to thrive (FTT) syndrome (see Mortality/Morbidity). Traditionally, nonorganic causes of failure to thrive have been thought to result in more cognitive deficits than found with organic causes. In addition, whether early intervention or home visits can affect development positively is unclear. In 1995, Black demonstrated that home intervention may reduce developmental delays, mainly cognitive delays in young children.8 In 1999, Raynor demonstrated that, although children who received home visits had less dietary referrals, social services involvement, and hospital admissions, no effect on growth was observed.9
Failure to thrive remains one of the greatest challenges for the practicing pediatrician. The process of the attempt at identification of the causes can be exhausting and expensive. The list of organic and nonorganic causes of this entity is extensive, and combinations of the 2 types of causes are common in specific children. Failure to thrive can have its roots in prenatal origins or can develop postnatally. Information from a careful extensive history and from a detailed physical examination may give important clues to the underlying diagnoses. Hospitalization and the involvement of a multispecialty team may be helpful in diagnosis.
Whether failure to thrive results from organic or nonorganic reasons, children with this condition require aggressive calorie supplementation; examples of the sources of such calories are summarized in Tables 2-3 of this article. The cognitive outcome of children who have had failure to thrive is not clear. However, a careful and timely search for the causes of failure to thrive and implementation of aggressive calorie supplementation is important in obtaining the best possible outcome in these children.
Patient Education
For excellent patient education resources, visit eMedicine's Growth Hormone Deficiency Center. Also, see eMedicine's patient education articles Growth Failure in Children, Growth Hormone Deficiency, Growth Hormone Deficiency in Children, and Growth Hormone Deficiency FAQs
http://emedicine.medscape.com/article/985007-print
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