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Evaluation and Management of The Child with Failure to Thrive

Article in Nigerian Hospital Practice · January 2011

DOI: 10.4314/nhp.v6i1-2.62334

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Alphonsus N. Onyiriuka
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 HOSPITAL CHRONICLES 2011, 6(1): 9–23

REVIEW

Evaluation and Management

of the Child With Failure to Thrive
Alphonsus N. Onyiriuka, MBBS, FMCPaed

A BSTR ACT

Department of Child Health, University

BACKGROUND: Failure to thrive (FTT) is a common problem in pediatric practice, af-
of Benin Teaching Hospital, Benin
fecting 5-10% of children under five years of age in developed countries with a higher
City, Nigeria
incidence in developing countries.
OBJECTIVE: To outline a simplified but detailed approach to determining the etiology
of FTT and highlight the need for high-calorie diet for catch-up growth and a careful
follow up.
METHODS: Data were collected using manual search for relevant journals at the Uni-
KEY WORDS: failure to thrive; versity of Benin Medical Library, internet (medline) search and textbooks.
growth deficiency; growth faltering;
RESULTS: The majority of cases of FTT are due to a combination of nutritional and
undernutrition
environmental deprivation secondary to parental poverty and/or ignorance. The key
to diagnosing FTT is by accurately measuring and plotting a child’s weight, height and
head circumference overtime and comparing the results with the appropriate growth
charts and then assess the trend. In the evaluation of the child who has failed to thrive,
three initial steps are required to develop an economical treatment-centered approach:
a thorough history including itemized psychosocial review, careful physical examina-
ABBREVIATIONS tion, and direct observation of the child’s behavior and of parent-child interaction.
FTT = failure to thrive Laboratory evaluation should be guided by history and physical examination findings
HIV = human immunodeficiency virus only. Two principles that hold true, irrespective of etiology, are that all children with
MPH = mid-parental height
FTT need a high-calorie diet for catch-up growth and all children with FTT need a
NFTT = non-organic failure to thrive
careful follow up. Social issues of the family must also be addressed.
CONCLUSION: A multidisciplinary approach is recommended when FTT persists de-
spite intervention or when it is severe.

Correspondence to:
INTRODUCTION
Alphonsus N. Onyiriuka
Department of Child Health
University of Benin Teaching Hospital Although the term failure to thrive (FTT) has been in use in the medical parlance
P.M.B. 1111 for quite some time now, its precise definition has remained debatable.1 Consequently,
Benin City, Nigeria other terms such as “undernutrition”1 and “growth deficiency”2 have been proposed
e-mail: alpndiony@yahoo.com / as preferable. “Growth faltering” refers to deviation from incremental growth rates in
didiruka@gmail.com the reference population. Failure to thrive is a descriptive term applied when a young
Manuscript received October 15, 2010; child’s physical growth is less than that of his or her peers.3 The growth failure may
Revised manuscript received and begin either in the neonatal period or after a period of normal physical development.4
accepted January 28, 2011 The term FTT is not, in itself, a disease but a symptom or sign common to a wide va-
 HOSPITAL CHRONICLES 6(1), 2011

riety of disorders which may have little in common except for is less than the third percentile.5,6 In the first 2 years of life, the
their negative effect on growth.5 In this regard, a cause must child’s weight changes to follow the genetic predisposition of
always be sought. the parent’s height and weight.13,14 During this time of transi-
Often, the evaluation of children who fail to thrive poses tion, children with familial short stature may cross percentiles
a difficult diagnostic problem. Some of the difficulties result downward and still be considered normal.14 This is more likely
from the numerous differential diagnoses, the definition used to occur in mating between tall mothers and short fathers.
or misdirected tendency to search aggressively for underlying Most children in this category find their true curve by the age
organic diseases while neglecting etiologies based on envi- of 3 years.6,14 The pediatrician must, therefore, understand the
ronmental deprivation.6 In addition, early accusations and phases of growth and close scrutiny of growth curves. When
alienation of the child’s parents by the health–care provider the percentile drop is great, it is helpful to compare the child’s
will make the evaluation and management of the child who weight percentile to height and head circumference percen-
has failed to thrive more difficult.7 tiles. These should be consistent with the position of height
In general, factors that influence a child’s growth include: and head circumference percentiles of the patient.5 Another
(i) a child’s nutritional status; (ii) a child’s health; (iii) family limitation of the third percentile as a criterion to define FTT
issues; (iv) the parent–child interactions; and (v) genetic fac- is that infants can be failing to thrive with marked deceleration
tors.3,8,9 All these factors must be considered in the evaluation of weight gain, but they remain undiagnosed and, therefore,
and management of a child who has failed to thrive. This paper untreated until they have fallen below the arbitrary third
presents a simplified but detailed approach to the evaluation percentile.6 These normal small children do not demonstrate
and management of the child with FTT. the disproportionate failure to gain weight that children with
FTT do.6 This approach attempts not only to prevent normal
small children from being incorrectly labeled as failing to
DEFINITION thrive, but also excludes children with pathologic proportionate
short stature.14 Having excluded these easily distinguishable
The best definition for FTT is the one that refers to it disorders from the differential diagnosis of FTT, simplifies the
as inadequate physical growth diagnosed by observation of approach to evaluation of the child who has failed to thrive.6
growth over time using a standard growth chart, such as the A more encompassing definition of FTT includes any child
National Center for Health Statistics (NCHS) growth chart.10 whose weight has fallen more than two standard deviations
All authorities agree that only by comparing height and weight from a previous growth curve.3,15,16 Normal shifts in growth
on a growth chart over time can FTT be assessed accurately.11 curves in the first 2 years of life will result in less severe decline
So far, no consensus has been reached concerning the specific (i.e., less than 2 standard deviations).13
anthropometric criteria to define FTT.11 Consequently, where Some authors have even limited the definition of FTT to
serial anthropometric records are not available, FTT has been only children less than 3 years old.17,18 A precise age limita-
variously defined statistically. For instance, some authors de- tion is arbitrary. However, most children with FTT are under
fined FTT as weight below the third percentile for age on the 3 years of age.6,8
growth chart or more than two standard deviations below the
mean for children of the same age and sex1-3 or a weight-for-
age (weight-for-height) Z-score less than minus two.1 Others EPIDEMIOLOGY
cite a downward change in growth that has crossed two major
growth percentiles in a short time.3 Still others, for diagnostic In young children, FTT which does not reach the severe
purposes, defined FTT as a disproportionate failure to gain classical syndrome of marasmus is common in all societies.19
weight in comparison to height without an apparent etiology.6 However, the true incidence of FTT is not known as many
Brayden et al 2 suggested that FTT should be considered if a infants with FTT are not identified, even in developed coun-
child less than 6 months old has not grown for two consecutive tries.20-22 It is estimated that FTT affects 5–10% of young
months or a child older than 6 months has not grown for three children and approximately 3–5% of children admitted into
consecutive months. Recent research has validated that the teaching hospitals.3,5,23 Mitchell et al,24 using multiple criteria,
weight-for-age approach is the simplest and most reasonable found that nearly 10% of under-fives attending a primary
marker of FTT.12 health care center in the United States manifested FTT. About
5% of pediatric admissions in the United Kingdom are for
P I T FA L L S O F D E F I N I T I O N S FTT.4 The prevalence is even higher in developing countries
One limitation of using the third percentile for defining with wide-spread poverty and high rates of malnutrition and/
FTT is that some children whose weight falls below this arbi- or HIV infections.3,19 Children born to single teenage mothers
trary statistical standard of normal are not failing to thrive but and working mothers who work for long hours are at increased
represent the three percent of normal population whose weight risk.22 The same is true for children in institutions such as or-

10
 FAILURE TO THRIVE

phanage homes and homes for the mentally retarded,5,22 with 2 . O R G A N I C FA I L U R E T O T H R I V E

an estimated incidence of 15% as a group.5 Under-feeding is It occurs when there is a known underlying medical cause.
the single commonest cause of FTT that results from parental Organic disorders causing FTT are most commonly infectious
poverty and/or ignorance.19,22,24 Ninety-five percent of cases of (e.g., HIV infection, tuberculosis, intestinal parasitosis), gas-
FTT are due to inadequate food offered or taken.25 The peak trointestinal (e.g., chronic diarrhea, gastroesophageal reflux,
incidence of FTT occurs in children between the age of 9–24 pyloric stenosis) or neurologic (e.g., cerebral palsy, mental
months, with no significant gender difference.22 The majority retardation) disorders.6,19,22 Others include genitourinary dis-
of children who fail to thrive are less than 18 months old.3 The orders (e.g., posterior urethral valve, renal tubular acidosis,
syndrome of FTT is uncommon after the age of 5 years.3,22 chronic renal failure, urinary tract infection -UTI), congenital
heart disease, and chromosomal anomalies.6,7 Urinary tract
infection is a major preventable and treatable cause of FTT and
CLASSIFICATION OF FTT all patients presenting with FTT should be evaluated in that
regard. Combined neurologic and gastrointestinal disorders
Traditionally, causes of FTT have been classified as non- account for 60–80% of all organic causes of under nutrition
organic and organic. However, some authors have stated that in developed countries.30 An important medical risk factor
this terminology is misleading.27 They base their opinion on the for under nutrition in childhood is premature birth.1 Among
fact that all cases of FTT are produced by inadequate food or preterm infants, those who are small for gestational age are
undernutrition and in that context, it is organically determined. particularly vulnerable since prenatal factors have already
In addition, the distinction based on organic and non-organic exerted a deleterious effect on somatic growth.1 In societies
causes is no longer favoured because many cases of FTT are where lead poisoning is common, it is a recognized risk factor
of mixed etiologies.3 for poor growth.5,31 Organic FTT virtually never presents with
Based on pathophysiology, which is the preferred classifica- isolated growth failure; other signs and symptoms are gener-
tion, FTT may be classified into those due to: (i) inadequate ally evident with a detailed history and physical examination.32
caloric intake; (ii) inadequate absorption; (iii) increased Organic disorders account for less than 20% of cases of FTT.6
caloric requirement, and; (iv) defective utilization of calories.
This classification leads to a logical organization of the many 3 . M I X E D FA I L U R E T O T H R I V E
conditions that cause or contribute to FTT.10 In mixed FTT, organic and non organic causes coexist.
Those with organic disorders may also suffer from environ-
1 . N O N - O R G A N I C ( P S YC H O S O C I A L) FA I L U R E
TO THRIVE
mental deprivation. Likewise, those with severe undernutrition
from non-organic FTT can develop organic medical problems.
In non-organic failure to thrive (NFTT), there is no known
medical condition causing the poor growth. It is due to poverty, 4. FTT W ITH NO SPECIFIC ETIOLOGY
psychosocial problems in the family, maternal deprivation, Review of the literature on FTT indicates that in 12–32% of
lack of knowledge and skill in infant nutrition among the care- cases of children who have failed to thrive, no specific etiology
givers.5,11 Other risk factors include substance abuse by parents, could be established.23,33,34
single parenthood, general immaturity of one or both parents,
economic stress and strain, temporary stresses such as family
tragedies (accidents, illnesses, deaths) and marital dishar- CAUSE S OF FA I LU R E T O T H R I V E
mony.6,8,22 Weston et al,28 reported that 66% of mothers whose
infants failed to thrive has a positive history of having been ç . PR E NATA L CAUSE S :
abused as children themselves, compared to 26% of controls (i) Prematurity with its complications; (ii) exposure in
from similar socioeconomic background. NFTT accounts for utero to toxic agents, such as alcohol, tobacco smoke, medi-
over 70% of cases of FTT.6 Of this number, approximately one- cations; (iii) infections (e.g., rubella, cytomegalovirus-CMV,
third is due to care-giver’s ignorance, such as incorrect feeding HIV); (iv) intrauterine growth restriction from any cause; (v)
technique, improper preparation of formula or misconception chromosomal abnormalities (e.g., Down syndrome, Turner
of the infant’s nutritional needs,29 all of which are easily cor- syndrome); and (vi) dysmorphogenic syndromes.
rected. A closer look at these risk factors for NFTT suggests
that infants with growth failure may represent a flag for serious B . P OST NATA L CAUSE S BA SE D
O N PA T H O P H Y S I O L O G Y
social and psychological problems in the family. For example,
a depressed mother may not feed her infant adequately. The 1. Inadequate caloric intake which may result from
infant may, in turn, become withdrawn in response to mother’s i. Under feeding.
depression and feeds less well.10 Extreme parental attention, ii. Incorrect preparation of formula (e.g., too dilute, too
either neglect or hypervigilance, can lead to FTT.10 concentrated).

11
 HOSPITAL CHRONICLES 6(1), 2011

iii. Behavior problems affecting eating (e.g., child’s tempera- ii. Chronic/recurrent infections e.g., UTI, respiratory tract
ment). infection, tuberculosis, HIV infection.
iv. Unsuitable feeding habits (e.g., uncooperative child). iii. Chronic anemias.
v. Poverty leading to food shortages.
vi. Child abuse and neglect. 4. Defective utilization of calories
vii. Mechanical feeding difficulties e.g., congenital anomalies i. Inborn errors of metabolism e.g., galactosemia, aminoaci-
(cleft lip/palate), oromotor dysfunction. dopathies, organic acidurias, storage diseases.
viii. Prolonged dyspnea of any cause ii. Diabetes insipidus/mellitus.
iii. Renal tubular acidosis.
2. Inadequate absorption which may be associated iv. Chronic hypoxemia.
with Risk factors for the development of FTT are summarized
i. Malabsorption syndromes e.g. celiac disease, cystic fibro- in Table 1.
sis, cow’s milk protein allergy, giardiasis, food sensitivity/
intolerance.
ii. Vitamins and mineral deficiencies e.g., zinc, vitamin A CLINICAL MANIFESTATIONS
and C deficiency. O F FA I L U R E T O T H R I V E 3,22
iii. Hepatobiliary diseases, e.g., biliary atresia.
iv. Necrotizing enterocolitis. Commonly the parents/care-givers may complain that the
v. Short gut syndrome. child is “not growing well” or “losing weight” or “not feeding
well” or “not doing well” or “not like his other siblings/age
3. Increased caloric requirement due to mates”. Usually FTT is discovered and diagnosed by the in-
i. Hyperthyroidism. fant’s physician using the birthweight and the anthropometric

TABLE 1. Summary of risk factors for the development of failure to thrive

Infant characteristics
‡$Q\FKURQLFPHGLFDOFRQGLWLRQUHVXOWLQJLQ
- Inadequate intake (e.g., swallowing dysfunction, central nervous system damage, anorexia)
- Increased metabolic rate (e.g., bronchopulmonary dysplasia, congenital heart disease, fever)
- Maldigestion or malabsorption (e.g, AIDS, cystic fibrosis, short gut, inflammatory bowel disease, celiac disease).
- Infections (e.g., HIV, TB, giardiasis)
‡3UHPDWXUHELUWK HVSHFLDOO\ZLWKLQWUDXWHULQHJURZWKUHVWULFWLRQ
‡'HYHORSPHQWDOGHOD\
‡&RQJHQLWDODQRPDOLHV
‡,QWUDXWHULQHH[SRVXUHWRWR[LFDJHQWV HJDOFRKROWREDFFRVPRNH
‡3OXPELVPDQHPLD
‡,QERUQHUURUVRIPHWDEROLVP HJ%12-dependent methylmalonic aciduria, biotinidase deficiency, etc)
Family characteristics
‡3RYHUW\
‡8QXVXDOKHDOWKDQGQXWULWLRQEHOLHIV
‡6RFLDOLVRODWLRQ
‡)DXOW\IHHGLQJWHFKQLTXHV
‡6XEVWDQFHDEXVHRURWKHUSV\FKRSDWKRORJ\ LQFOXGLQJ0XQFKDXVHQV\QGURPHE\SUR[\
‡9LROHQFHRUDEXVH
AIDS = acquired immunodeficiency syndrome; HIV = human immunodeficiency virus; TB = tuberculosis
Adapted from Kleinman RE.1

12
 FAILURE TO THRIVE

records of the child. TABLE 2. Summary of history taking in infants and children
The infant looks small for age. The child may exhibit loss with growth failure
of subcutaneous fat, reduced muscle mass, thin extremities,
Prenatal
narrow face, prominent ribs, and wasted buttocks. Evidence of
neglected hygiene, such as diaper rash, unwashed skin, over- General obstetrical history
grown and dirty fingernails or dirty clothing. Other findings Recurrent miscarriages
may include avoidance of eye contact, lack of facial expression, Was the pregnancy planned?
absence of cuddling response, hypotonia and assumption of Use of medications, drugs, or cigarettes
infantile posture with clenched fists. There may be marked Labour, delivery, and neonatal events
preoccupation with thumb sucking. Neonatal asphyxia/Apgar scores
Prematurity
E VA L UAT I O N Small for gestational age
Birth weight and length
A . I N I T I A L E VA L UA T I O N Congenital malformations or infections
It has been proposed that only three initial investigations Maternal bonding at birth
are required to develop an economical, treatment-centered ap- Length of hospitalization
proach to the child that presents with FTT; these include:35 (a) Breastfeeding support
a thorough history, including an itemized psychosocial review; Feeding difficulties during neonatal period
(b) careful physical examination, including determination of Medical history of child
the auxological parameters; and (c) direct observation of the
Regular physician
child’s behavior and of parent-child interaction.
Immunizations
a. History (Table 2) Development
1. Nutritional history. Nutritional history should include: Medical or surgical illnesses
i. Details of breast feeding including the number of feed- Frequent infections
ings, the time interval between feedings, whether both Growth history
breasts are given or only one breast, whether feeding is Plot previous measurements
continued at night or not, and what the child’s behavior Nutrition history
is before, after and between feedings. This information
Feeding behavior and environment
should give an idea of the adequacy or inadequacy of
mother’s milk. If the infant is on formula, it should be Perceived sensitivities or food allergies
clarified whether the formula is prepared correctly. Quantitative assessment of intake (3-day diet record, 24-hour
Overdiluted milk will provide a poor caloric intake. food recall)
Too concentrated milk may be unpalatable leading to Social history
refusal to drink. It is also essential to know the total Age and occupation of parents
quantity of the formula consumed. Is it given by bot- Who feeds the child?
tle or cup and spoon? Also, the feeling of the mother Life stressors (loss of job, divorce, death in family)
should be assessed, e.g., ask “how do you feel when
Availability of social and economic support
the baby does not feed well?” Time of introduction of
complementary feedings and any difficulty should be Perception of growth failure as a problem
noted. History of violence or abuse of care-giver
ii. Vitamin and mineral supplements; when started, type, Review of systems/clues to organic disease
amount, duration. Anorexia
iii. Solid food; when started, types, how taken. Change in mental status
iv. Appetite; whether the appetite is temporarily or per- Dysphagia
sistently impaired (if necessary calculate the caloric Stooling pattern and consistency
intake).
Vomiting or gastroesophageal reflux
v. For older children enquire about food likes and dis-
Recurrent fever
likes, allergies or idiosyncracies. Is the child fed forci-
bly? It is desirable to know the feeding routine from Dysuria, urinary frequency
the time the child wakes up in the morning until the Activity level, ability to keep up with peers
night. This gives an approximation of the total caloric Source: Duggan C.46

13
 HOSPITAL CHRONICLES 6(1), 2011

intake and the calories supplied from protein, fat and dermatitis may constitute features of Menkes disease or bioti-
carbohydrate as well as the adequacy of vitamins and nidase deficiency. In general, the detection of multiple organ
minerals intake. system involvement in a child with FTT should raise suspicion
2. Past and current medical history. The history should of some underlying inborn error of metabolism.
include information of prenatal care, maternal illnesses The basic growth parameters, such as weight, height/length,
during pregnancy, identified fetal growth problems, pre- head circumference and mid-upper-arm circumference must
maturity and birth weight. Indicators of medical diseases be measured carefully. Recumbent length is measured in
such as vomiting, diarrhea, fever, respiratory symptoms and children below 2 years of age because standing measurements
fatigue should be noted. Past hospitalizations, injuries and can be as much as 2 cm shorter.36,37 Other anthropometric data
accidents that are useful for the evaluation of child abuse such as upper-segment to lower-segment ratio, sitting height
or neglect should be recorded. Information about stool and arm span should also be recorded. The anthropometric
pattern, frequency, consistency, or presence of blood or index used for FTT should be weight-for-length or height.
mucus is needed to evaluate the possibility of malabsorp- Mid-parental height (MPH) should be determined by using
tion syndromes, infection or allergy. the formula: MPH = [FH+(MH–13)] / 2 or MPH = [(FH–
3. Family and social history. Family and social history should 13)+MH] / 2 for boys and girls respectively,40 where FH is the
include number, age and sex of siblings. Ascertain age of father’s height and MH is the mother’s height in cm. The target
parents (Down syndrome and Klinefelter syndrome in range is calculated as the MPH±8.5 cm, representing the two
children of elderly mothers) and the child’s place in the standard deviations (2SD) confidence limits.14
family (pyloric stenosis). Family history should include 1. Assessment of degree of FTT. The degree of FTT is usually
growth parameters of siblings. Are there other siblings measured by calculating each growth parameter (weight,
with FTT (e.g., genetic causes of FTT), or family members height and weight/height ratio) as a percentage of the
with short stature (e.g., familial short stature)? The social median value for age based on appropriate growth charts3
history should determine occupation of the parents and (Table 4).
family income, and identify those caring for the child. Also It should be noted that appropriate growth charts are often
child factors (e.g., temperament, development), parental not available for children with specific medical problems
factors (e.g., depression, domestic violence, social isolation, and, therefore, serial measurements are especially impor-
mental retardation, substance abuse), and environmental tant for these children.3 For premature infants, correction
and societal factors (e.g., poverty, unemployment, illit- must be made for the extent of prematurity. Corrected age,
eracy) should be evaluated, all of which may contribute rather than chronologic age, should be used in calculations
to growth failure.5 of their growth percentiles until 1-2 years of corrected age.3
4. Psychosocial review. The psychosocial history should be Growth charts should be used for evaluating the pattern
as thorough and systematic as a classic physical examina- of FTT. If weight, height and head circumference are all
tion. Goldbloom35 suggested that the interviewer should less than what is expected for age, this may suggest an
ask himself three questions about every family: (i) how do insult during intrauterine life or genetic/chromosomal
they look; (ii) what do they say; and (iii) what do they do? factors.2 If weight and height are delayed with a normal
Aspects of history needed for the evaluation of the child head circumference, endocrinopathies or constitutional
with FTT are summarized in Table 2. growth retardation should be suspected.2 When only weight
gain is delayed, this usually reflects recent energy (caloric)
b. Physical examination (Table 3) deprivation.2
The four main goals of physical examination include (i) Physical examination in infants and children with FTT is
identification of dysmorphic features suggestive of a genetic summarized in Table 2.
disorder that affects growth; (ii) detection of an underlying 2. Failure to thrive due to environmental deprivation.
disease that may impair growth; (iii) assessment for signs of Children with environmental deprivation primarily dem-
possible child abuse; and (iv) assessment of the severity and onstrate signs of failure to gain weight: loss of fat, promi-
possible effects of malnutrition.36,37 Detection of organomegaly nence of ribs and muscle wasting, especially in large muscle
(hepatomegaly and/or splenomegaly) will turn suspicion to groups, such as the gluteals.6
metabolic disorders such as lysosomal storage disorders, 3. Developmental assessment. It is important to determine
galactosemia, glycogen storage disorders, etc. Neurologic the child’s developmental status at the time of diagnosis
dysfunction may indicate mitochondrial, storage, amino acid because children with FTT have a higher incidence of
or organic acid disorders, or urea cycle defects. Certain developmental delays than the general population.36 In en-
dysmorphic features will point to peroxisomal disorders, mu- vironmental deprivation, all milestones are usually delayed
copolysaccharidosis, glutaric aciduria type II, etc. Hair and once the infant reaches 4 months of age.42 Areas dependent
skin abnormalities such as kinky hair, alopecia, or seborrheic on environmental interactions, such as language develop-

14
 FAILURE TO THRIVE

TABLE 3. Physical examination of infants and children with growth failure.

Organ/function Abnormality Diagnostic Consideration

Vital signs Hypotension Adrenal or thyroid insufficiency
Hypertension Renal diseases
Tachypnea/Tachycardia Increased metabolic demand
Skin Pallor Anemia
Poor hygiene Neglect
Ecchymoses Abuse
Candidiasis Immunodeficiency, HIV infection
Eczema Allergic disease
Erythema nodosum Ulcerative colitis, vasculitis
HEENT Hair loss Stress
Chronic otitis media Immunodeficiency, structural oro-facial defect
Cataracts Congenital rubella syndrome, galactosemia
Aphthous stomatitis Crohn’s disease
Thyroid enlargement Hypothyroidism
Chest Wheezes Cystic fibrosis, asthma
Cardiovascular Murmur Congenital heart disease(CHD)
Abdomen Distension, hyperactive bowel sound, Malabsorption, liver disease, glycogen storage
hepatosplenomegaly disease
Genitourinary Diaper rashes Diarrhea, neglect
Rectum Empty ampulla Hirschsprung’s disease
Extremities Edema Hypoalbuminemia
Loss of muscle mass Chronic malnutrition
Clubbing Chronic lung disease, cyanotic CHD
Nervous system Abnormal deep tendon reflexes Cerebral palsy
Developmental delay Altered caloric intake or requirements
Dysphagia Cranial nerve palsy
Behavior & temperament Uncooperative Difficult to feed.
CHD = congenital heart disease; HEENT = head, ears, eyes, neck & throat (examination)
Adapted from Collins et al 41

TABLE 4. Assessment of degree of failure to thrive responses to approach and withdrawal) have been devel-
oped to help differentiate environmental deprivation from
Degree of Failure to Thrive
underlying organic disease.43 The infant’s developmental
Growth parameter Mild Moderate Severe status should be assessed with a full Denver Developmental
Weight 75-90% 60 -74% <60% Standardized test.44

Height 90 -95% 85 – 89% <85% c. Parent-child interaction

Weight/height ratio 81-90% 70 -80% <70% Evaluate interaction between the parents and the child dur-
ing the examination. In environmental deprivation, the parent
Adapted from Baucher H.3
often readily walks away from the examination table and easily
abandons the child to the nurse or physician. There is little
ment and social adaptation are often disproportionately eye contact between child and parent and the infant is kept
delayed. Specific behavioral evaluations (e.g., recording distantly, with little moulding to the parent’s body. Often the

15
 HOSPITAL CHRONICLES 6(1), 2011

infant will not reach out for the parent and little affectionate (e.g. galactosemia), and ketonuria (glycogen storage disease).
touching is noted. There is little parental display of pleasure In these cases the patient should be referred to a metabolic
towards the infant.6 specialist for further and more specific metabolic testing.
Observation of feeding is an integral part of the examina-
tion, but it is ideally done when the parents are not aware that C . F U R T H E R E VA L UA T I O N
they are being observed. Breast-fed infants should be weighed 1. Hospitalization: Although some authors state that most
before and after several feedings over a 24-hour period since children with failure to thrive can be treated as outpa-
the volume of milk consumed may vary with each meal. In tients,4,5,11,45 I think it is better to hospitalize the infant
environmental deprivation, the parents often miss the infant’s with FTT for 10 – 14 days. Hospitalization has both diag-
cues and they may distract the infant during feeding; the infant nostic and therapeutic benefits. The diagnostic benefits
may also turn away from food and appear distressed.6 Also, of admission include observation of feeding, parental-
unnecessary force may be used during feeding. Developing child interaction, and consultation of sub-specialists. The
a portrait of the child-parent relationship is key to guiding therapeutic benefits include administration of intravenous
intervention.11 fluids for dehydration, systemic antibiotic treatment for
infection, blood transfusion for severe life-threatening
B . L A B O R A T O R Y E VA L UA T I O N
anemia and possibly parenteral nutrition, all of which are
The role of laboratory studies in the evaluation of FTT is often in-hospital procedures. In addition, if an organic
to investigate for the presence of possible organic disorders etiology is discovered for the FTT, specific therapy can
suggested by the history and physical examination.33,34 If an be initiated during hospitalization. In psychosocial FTT,
organic etiology is suggested, appropriate studies should be hospitalization provides the opportunity to educate parents
undertaken. If history and physical examination do not suggest about appropriate foods and feeding styles for infants.
an organic etiology, an extensive laboratory investigation is Hospitalization is necessary when the safety of the child
not indicated.6 However, on admission complete blood count, is a concern. In most situations in our set up, there is no
erythrocyte sedimentation rate, urinalysis, urine culture, urea viable alternative to hospitalization.
and electrolyte (including calcium and phosphorus) levels 2. Quantitative assessment of intake: A prospective 3-day
should be carried out. Screening for infections, such as HIV diet record should be a standard part of the evaluation. This
infection, tuberculosis and intestinal parasitosis should be is useful in assessing undernutrition even when organic
performed. Skeletal survey is indicated if physical abuse is disease is present. A 24-hour food recall is also desirable.
strongly suspected. In addition to being unproductive, blind Having parents write down the types of food and amounts
laboratory fishing expeditions should be avoided for the fol- a child eats over a three-day period is one way of quantify-
lowing reason:5,6 (i) they are expensive; (ii) they impair the ing caloric intake. In some instances, it can make parents
child’s ability to gain weight in a new environment both by aware of how much the child is or is not eating.11
frightening the child with venipunctures, barium studies and
other stressful procedures and the restriction of feedings
associated with some investigations prevent the child from DI F F ER EN T I A L DI AGNOSIS
getting enough calories; (iii) they can be misleading since a OF FA I LU R E T O T H R I V E
number of laboratory abnormalities are associated with psy-
chosocial deprivation (e.g., increased serum transaminases, 1 . FA M I L I A L S H O R T S TAT U R E
transient abnormalities of glucose tolerance, decreased growth Although children with familial short stature often are
hormone and iron deficiency);21 and (iv) they divert attention close to the third percentile on the growth chart, they have
and resources from the more productive search for evidence normal weight-to-height ratio and growth velocity, their bone
of psychosocial deprivation. In one study, a total of 2,607 age is equal to their chronological age, and they look happy
laboratory studies were performed, with an average of 14 tests and healthy.47 Their growth curve runs parallel to and just
per patient. With all tests considered, only 10 (0.4%) served below the normal curves.48
to establish a diagnosis and an additional 1% were able to
support a diagnosis.34 2 . CONST I T U T IONA L GROW T H DEL AY
Finally, routine laboratory tests may provide clues for an In constitutional growth delay, weight and height start to
inborn error of metabolism, such as hypoglycemia (disorders decrease near the end of infancy, parallel the normal growth
of carbohydrate metabolism), abnormal liver function tests curves through middle childhood, and accelerate toward the
(e.g. galactosemia, mitochondrial disease, etc.), decreased bi- end of adolescence.48 Growth velocity during childhood is
carbonate (HCO3) levels (hyperchloremic metabolic acidosis), normal, bone age is delayed, puberty is delayed, health is
metabolic acidosis particularly with high anion gap (a feature otherwise normal, and usually they have a family history of
of organic acidemias), urine positive for reducing substance delayed growth and puberty.47

16
 FAILURE TO THRIVE

3 . E A R LY ONS E T GROW T H DE L AY ment.66 Usually the age at onset is between 18 and 24 months.66
About 25% of normal infants will shift to lower growth Affected children are often shy, passive, typically depressed
percentile in the first two years of life and then follow that and socially withdrawn.5 The short stature may or may not be
percentile.11,49 This should not be diagnosed as failure to thrive. associated with concomitant FTT.5
Smith et al13 reported that 30% of healthy, full-term, white
infants cross one percentile line and 23% cross two percentile
lines as they proceed from birth to the age of 2 years. In both M A NAGEM EN T OF T H E CH I LD
W I T H FA I LU R E T O T H R I V E
history and physical examination, there are no remarkable
findings except that similar features may be found in other
siblings in the family.23 Although in some children puberty Treatment of FTT is both immediate and long-term and
may be delayed, a normal pubertal growth spurt occurs later should be directed at both the infant and the mother/family.
in adolescence.23 The bone age corresponds to the height age.23 A good treatment plan must address the following:
1. The child’s diet and eating pattern.
4 . S P E C I F I C I N FA N T P O P U L AT I O N S 2. The child’s developmental stimulation.
Preterm infants and those who suffered intrauterine 3. Improvement in care-giver skills.
growth restriction may demonstrate growth failure in the im- 4. Nursing considerations in the treatment of FTT.
mediate postnatal period50,51 but a catch-up growth has been 5. Presence of any underlying disease.
reported to occur during the first 2 to 3 years of life.52,53 As 6. Regular and effective follow up.
long as the child’s growth follows a curve with a normal interval 7. Consultation and referral to specialists.
growth rate, FTT should not be diagnosed.54 Over diagnosis
1 . T H E C H I L D ’ S D I E T A N D E A T I N G PA T T E R N
of growth failure can be avoided by using modified growth
charts developed for specific populations, such as preterm The mainstay of management of failure to thrive, regard-
infants,55,56 exclusively breast fed infants,57,58 specific ethnici- less of etiology, is nutritional intervention and feeding behav-
ties (e.g., Asians)59,60 and infants with genetic syndromes such iour modifications. For breast-fed infants, the feeding interval
as Down61 and Turner62,63 syndromes. Use of these charts can should not be greater than four hours and the maximum
help to reassure the physician that these children are growing time allowed for suckling should be 20 minutes. Beyond this
appropriately. time the infant becomes tired. The behavioural modification
In preterm infants, their chronological age should be should center on improving feeding techniques, avoiding large
corrected by gestational age until the age of 24 months for amount of juices and eliminating distractive events, such as
weight measurements, 40 months for length, and 18 months watching television during meals. Excessive fruit juice intake is
for head circumference.1 This is a crude method because it an important contributor to poor growth because it provides a
does not capture the variability in growth velocity that very low carbohydrate intake and diminishes the appetite for nutri-
low birthweight infants demonstrate.48 Exclusively breast-fed tious meals.67 Successful management of FTT is followed by a
infants tend to plot higher for weight in the first 6 months of catch-up growth.19 Catch-up growth refers to gaining weight
life but relatively lower in the second half of the first year.48 at a rate greater than the 50th percentile for age (Fig. 1).68 For
obtaining a catch-up growth, children with FTT require 1.5
5. DIENCEPH A LIC SY NDROME to 2 times the expected calorie intake for their age.25 Details
This syndrome must be differentiated from psychosocial are shown in Table 5.
FTT. The diencephalic syndrome normally presents in the
Formula for calculation of catch-up growth
first year of life with failure to thrive, emaciation, increased
requirement30
appetite, euphoric affect and nystagmoid eye movements.64,65
Clinically they differ from FTT because in contrast to their Kcal or protein(g) for weight age x ideal body weight
poor physical condition they are alert, happy, active, relate Actual weight
easily and are not depressed.65 The diencephalic syndrome
results from neoplasms in the area of the hypothalamus and Some children with FTT are anorexic and picky eaters.
the third ventricle.64 They may, therefore, not be able to obtain the required amount
of calories and, therefore, they need calorie-dense feeds. Tod-
6 . PS YCHOSOC I A L SHORT STAT U R E dlers can receive more calories by adding taste-pleasing fats
( P S YC H O S O C I A L DWA R F I S M ) such as cheese or butter, and where not feasible palm oil, to
Psychosocial dwarfism is a syndrome of deceleration of common toddler foods. In addition, vitamin and mineral sup-
linear growth combined with characteristic behaviour dis- plementation is required. Although some practitioners add
turbances (sleep disorder and bizarre eating habits), both of zinc to reduce the energy cost of weight gain during catch-up
which are reversible by a change in the psychosocial environ- growth, the data about its benefit are controversial.69,70 Meals

17
 HOSPITAL CHRONICLES 6(1), 2011

The first priority is to achieve an ideal weight-for-age.

The second goal is to attain a catch-up in length that is close
to that expected for the child’s age. Steps in the treatment
are directed towards both immediate and long-term normal
growth of the child.72
Effectiveness of therapy is monitored by gain in weight.
Weight gain in response to adequate caloric intake usually
establishes the diagnosis of psychosocial FTT.3,23 If FTT con-
tinues during hospitalization despite adequate dietary input,
the presence of an occult organic disease is most likely and
requires further investigation.23 Adequacy of weight gain varies
with age (Table 6).
Calculation of daily or monthly growth, such as weight
gain in grams per day (Table 6), allows for more precise
comparison of growth rate to the normal.48 Although length
growth is harder to assess, it should be 0.2 to 0.4 mm per day
in most children.73
FIGURE 1. Failure to thrive and catch-up growth related to
weight centile. 2 . THE CHILD’S DEV ELOPMEN TA L
Source (with permission): Poskitt EME.19 STIMUL ATION
An organized program of intensive environmental stimula-
tion and affection during waking hours that utilizes parents,
TABLE 5. Average amount of carbohydrate and protein volunteers and child-life (social) workers is necessary.33 Tem-
required for catch-up growth. porary or permanent foster home may be required to eliminate
an adverse psychosocial environment. Studies have shown that
Age Kcal/kg Protein(g)/kg appropriate psychosocial stimulation is important for cognitive
0 – 6 months 115 2.2 development, both early and later in the child’s life.74,75
6 – 12 months 105 2.0
3. I M PROV E M EN T I N CA R E - GI V E R SK I L L
1 – 3 years 100 1.8
Parents should be counselled about family interactions that
4 – 6 years 85 1.5 are damaging to the child. Pay attention to the care-giver abil-
Source: Vinton NE et al30 ity to recognize the child’s cues, responsiveness, and parental
warmth and appropriate behaviour towards the child. Ensuring
that food is appropriately prepared and presented, and making
allowances for any difficulties that the child has in chewing
should be pleasant, regularly scheduled, and the child should and swallowing may all lead to improvement.3 Introduction of
not be fed too rapidly or too slowly. Starting with small amount solids in small frequent feedings is useful. Infants should be
of food and gradually offering more is preferable to beginning fed in semi-upright position.76 All staff members must work
with large quantities. Snacks need to be timed between meals constructively with the parents, increasingly passing responsi-
so that the child’s appetite will not be affected. The type of
caloric supplementation must be based on the severity of
FTT and the underlying medical condition. For instance, the
TABLE 6. Acceptable weight gain per day according to age.
amount of protein in the diet must be carefully monitored in
children with renal failure.3 Children with severe malnutrition Age (months) Weight gain (g/day)
must be re-fed carefully to prevent re-feeding syndrome.3,67 Birth to <3 20 – 30
For older infants and young children with psychosocial FTT,
3 to <6 15 – 22
meals should last for about 30 minutes, solid foods should be
offered before liquids, environmental distraction should be 6 to <9 15 – 20
minimized and children should eat with other people and not 9 to <12 6 – 11
be force-fed.71 The primary physician may consider consult-
12 to <18 5–8
ing a pediatric dietician to help provide a calorie-dense diet.
18 to 24 3–7
Monitoring nutritional therapy Source: Brayden et al2

18
 FAILURE TO THRIVE

bility back to them. They should avoid judgmental utterances. hospital is probably less difficult than maintaining adequate
Engaging the parents as co-investigator is essential. It helps long-term nutritional intake and developmental stimulation
foster their self-esteem and avoids blaming those who may at home.37 Children with FTT should be followed up at least
already feel frustrated and guilty because of perceived inability every 4 weeks until catch-up is demonstrated and the positive
to nurture their child. trend maintained.

4. NURSING CONSIDER ATIONS 7. C O N S U LTAT I O N A N D R E F E R R A L

I N T H E M A NAGEM EN T OF F T T T O SPE C I A L IST(S)
A nursing-care plan should include careful charting of For children who are not improving because of an undi-
intake, weight, and observations of the mother’s feeding agnosed medical condition or a particularly challenging social
style and interaction with the child. The nursing staff should situation, a multidisciplinary approach may be required.10,78
instruct the mother on how to improve behaviours that may Determining whether FTT is an isolated finding is crucial
be deprivational, including instructions on how to hold the in deciding to proceed with further metabolic tests or with
infant close during feeding. referral to a metabolic specialist. Children with multisystem
The mother should be taught how to cook locally available progressive findings are more likely to be afflicted by an inborn
foods. Foods should be thickened to increase caloric density error in metabolism and certainly need further investigation
and hence intake. Parents should be educated about the child’s to establish the correct diagnosis. Figure 2 shows a schema of
nutritional and psychological requirements. The child should clinical approach to management of a child presenting with
be stimulated by maternal care, affection and social interaction FTT. Although some exceptions to this schema may exist, it
with toys and peers. Home visits by a community health nurse is appropriate for most cases.
to assess family dynamics and economic situation is important.
Parental anxiety about the child’s FTT can be allayed by reas-
surance from the nurse. PR E V E N T ION OF FA I LU R E T O T H R I V E

5 . U N DE R LY I NG ORG A N IC DI S E A S E Promotion of exclusive breast feeding for early infancy,

Treat vigorously any identified underlying organic disease. followed by optimum complementary feeding in the presence
Often the underlying cause of FTT syndrome remains unclear. of good hygienic practices diminishes the risk of infections,
In this case an empiric trial of nutritional therapy by a person promotes infant growth and prevents child undernutrition.79
experienced in feeding infants along with careful observation Community effort to educate and encourage people to seek
and support of the family is necessary. Children with FTT help for their social, emotional, economic and interpersonal
due to infection must be evaluated and treated promptly. The problems may help reduce the incidence of psychosocial FTT.
synergistic relationship between nutritional status and infec- Encouraging parenting education courses in secondary
tion is particularly evident during infancy. Special attention schools as well as educational community programs may help
should be paid to uncover possibly treatable inborn errors of new parents enter parenthood with an increased knowledge
metabolism, particularly when FTT persists despite increased of infant’s nutritional and other needs.
caloric intake through diet. Of course, in metabolic disorders Early detection of FTT and intervention can reduce the
rarely is FTT an isolated symptom, and one must evaluate the severity of symptoms, enhance the process of normal growth
full spectrum of clinical findings. and development, and improve the quality of life experienced
by infants and children.
6 . R EGUL A R FOLLOW UP Prevention of low birthweight (a risk factor for FTT)
Upon discharge, close follow-up with home visits is essen- through balanced energy-protein supplementation, micro-
tial to ensure maintenance of nutritional status. In this regard, nutrient supplementation, treatment of infection/malaria,
Wright et al77 have shown that home nursing visits are associ- cessation of smoking and alcohol ingestion in pregnancy are
ated with better outcomes. Follow-up should ensure that the major interventions capable of preventing low birthweight.80
child is indeed now thriving normally by observing the growth Neonatal screening for treatable metabolic disorders (e.g.
parameters and using the appropriate growth charts. It also thyroid function tests, blood testing for phenylketonuria,
ensures that the child continues to receive adequate nutrition galactosemia, etc.)
at home. Cognitive development should be monitored and,
where necessary, additional stimulation should be provided at
home or in a preschool facility. The period of convalescence, COMPLICATIONS
which should encompass calorie-dense diet, is essential for full
recovery of children with FTT. Regular effective follow-up is 1. Malnutrition-infection cycle: recurrent infection exacer-
critical, in that achieving nutritional and growth recovery in bates malnutrition, which in turn leads to greater suscep-

19
 HOSPITAL CHRONICLES 6(1), 2011

FIGURE 2. Algorithm of management of child with FTT. CBC = complete blood count; ESR = erythrocyte sedimentation rate; FTT
= failure to thrive; HIV = human immunodeficiency virus; TB = tuberculosis

tibility to infection. Children with FTT must be evaluated function, edema, or feeding intolerance.68 If any of these
and treated promptly for infection. occur, stop further caloric increases until the child’s clinical
2. Re-feeding syndrome: re-feeding syndrome is character- status stabilizes.
ized by fluid retention, hypophosphatemia, hypomagne- 3. Chronic, severe undernutrition in infancy may depress head
semia and hypokalemia.68 To avoid the re-feeding syn- growth, an ominous predictor of later cognitive disability.3
drome, when nutritional rehabilitation is initiated, calories
can safely be started at 20% above the child’s recent
intake.68 If no estimate of caloric intake is available, 50 to PROGNOSIS
75% of the normal energy requirement is safe.68 If toler-
ated, caloric intake can be increased by 10 to 20% per day, The timing of the insult, the duration and severity of the
with monitoring for electrolyte imbalances, poor cardiac disease that caused growth failure determine the ultimate

20
 FAILURE TO THRIVE

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is often debated. A short period of poor growth is likely to 2. Brayden RM, Daley MF, Brown JM. Ambulatory and commu-
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Oxford, Oxford University Press, 1991:78–84.
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