Failure to Thrive

Published on 06/06/2015 by admin

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17 Failure to Thrive

Carrie Daymont, Beth Rezet

Definition

Failure to thrive (FTT) is a growth deficit in infancy and early childhood. FTT is usually defined as both poor weight gain and low weight for age defined as falling below the 3rd or 5th percentile on a growth curve representative of the population. Poor weight gain can be defined as crossing two decreasing major percentile lines or a rate of weight gain that is less than 2 standard deviations below the mean for age (assessed using weight velocity curves). Weight is affected earlier and more severely than length in FTT.

Etiology and Pathogenesis

FTT can arise from organic disease or nonorganic (psychosocial) factors and is very often multifactorial. The underlying cause of FTT in almost all cases is undernutrition.

Nonorganic Factors

Various psychosocial factors can lead to FTT. Child characteristics such as low appetite, food aversion, and oral-motor dysfunction make children susceptible to FTT and may interact with caregiver and social factors that exacerbate the problems. Many of the same psychosocial conditions that lead to FTT are also risk factors for obesity, suggesting that individual children respond to the same factors differently.

Although FTT can occur in children of all social classes, children living in poverty are disproportionately affected by FTT. Many children in the United States and other developed countries are “food insecure” and do not consistently have access to a minimally nutritious diet. This is particularly a problem in families that depend on the federal Women Infants and Children (WIC) program, which provides formula and food to supplement what a family is able to provide. Families may attempt to extend the supplement to supply all of an infant’s nutritional needs not realizing the dangers of using a diluted baby formula that is prepared with additional water. Supplemental coupons from WIC or food stamps are not intended to supply all of a family’s nutritional needs.

Even if a family is food secure, stressors associated with poverty can cause attachment problems, leading to difficulty in feeding for susceptible children. Families living in shelters or with many family members may have little control over when and where children are fed. Children whose temperaments and appetites require more routine or more frequent meals sometimes fail to thrive in these settings. Domestic violence can be associated with FTT through its detrimental effects on the caregiver, child, or both. Caregiver mental or physical illness, including postpartum depression (Figure 17-1), can also lead to disturbances of attachment. Children who are failing to thrive are at increased risk for abuse and neglect compared with the general population, but most experts believe that the majority of children with FTT are not abused or neglected (Figure 17-2). Some children in stressful living environments appear to have problems absorbing and using calories for growth because they grow poorly despite apparently adequate caloric intake and lack of organic causes for growth failure.

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Figure 17-1 Postpartum depression.

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Figure 17-2 Signs of neglect.

Cognitively impaired caregivers may prepare formula improperly or lack knowledge of an appropriate toddler diet. Some children prefer fruit juice or another single food over more nutrient-dense choices, and caregivers may not recognize this as a problem or be effective in encouraging children to eat a more balanced diet.

Caregiver health beliefs may also contribute to FTT. The influence of cultural expectations and norms, a parent’s relationship with the medical system, and individual beliefs may result in a family’s resistance to recognition of the problem or acceptance of intervention. Some caregivers may be so vigilant and concerned about nutrition and obesity that they may choose a restricted diet that is not appropriate for their child’s age.

Organic Factors

Organic factors can cause FTT by decreasing intake, decreasing absorption, or increasing metabolic demands. For example, poor motor coordination can cause decreased intake; celiac disease can cause malabsorption, and heart failure can increase metabolic demands.

Clinical Presentation

Patients may present throughout infancy and early childhood, although most cases of FTT start in the first year of life. Weight is generally affected earlier and more severely than length. Psychosocial dwarfism is a distinct problem that occurs in patients older than 3 years of age and primarily affects height. Waterlow’s categorization of FTT as mild, moderate, and severe is determined by comparing a child’s growth parameters with the median values for the child’s age and height. Growth patterns demonstrating each of the three classes of FTT are shown in Figure 17-3.

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Figure 17-3 Growth chart with points depicting growth patterns of mild, moderate, and severe failure to thrive.

Children who were born prematurely or with intrauterine growth retardation (IUGR) should be evaluated in the context of their gestational age and birth weight. Many children with prematurity and IUGR will catch up to their peers; however, if these children have not started to show significant catch-up growth in the first 6 months of life, they are unlikely to reach normal size. Children of short parents may be of low height and weight because of their genetic potential; however, the parents may have not reached their full genetic potential secondary to their own malnourishment as children.

Children with FTT generally have decreased height and weight in middle childhood compared with children who grew adequately during infancy. Long-term cognitive delays had been a concern for these children in the past, but recent research using community-based, rather than hospital-based patient samples, shows no significant difference in IQ between children with a history of FTT and children with adequate growth.

Differential Diagnosis

The differential diagnosis for FTT is broad and often multifactorial. As already noted, many psychosocial stressors and many chronic medical conditions could contribute to FTT. A list of some conditions to consider in the differential diagnosis is presented in Box 17-1.

Box 17-1 Differential Diagnosis of Failure to Thrive

Conditions to Consider

Nonorganic or Psychosocial

• Child abuse
• Domestic abuse of caregiver
• Food insecurity
• Disturbed attachment
• Caregiver mental or physical illness
• Neglect of child
• Chaotic living situation (e.g., shelter)
• Caregiver health beliefs

Allergic

• Food allergy

Cardiovascular

• Congenital heart disease
• Cardiomyopathy

Endocrine

• Hypothyroidism

Gastrointestinal

• Celiac disease*
• Chronic diarrhea
• Gastroesophageal reflux

Genetic

• Prader-Willi syndrome (in infancy)
• Silver-Russell syndrome

Hematologic

• Schwachman-Diamond syndrome

Immunologic

• HIV*

Infectious Disease

• Giardia*
• Urinary tract infection*

Metabolic

• Galactosemia

Neurologic

• Spinal muscular atrophy

Renal

• Renal tubular acidosis*

Respiratory

• Cystic fibrosis*
• Obstructive sleep apnea

* In persistent FTT, these conditions should be considered even in the absence of signs or symptoms.

Evaluation and Management

Evaluation

Diet and Feeding

A 3-day diet history detailing the quantity and frequency of specific liquids and solids should be obtained. In infancy, evaluation of breast feeding includes observation of the nursing dyad, attention to proper latching and positioning, the duration and frequency of feeds, and assessment of maternal diet and medical history. For formula-fed infants, correct formula preparation in addition to the frequency and quantity of feeds should be addressed. Many foods, such as juice and typical snack foods, are calorie rich but not nutrient dense and can displace more nutritious food, leading to poor weight gain.

Assessing the feeding environment, including the child’s behavior during feeding and the parents’ response to the child as well as the location, timing, and consistency of feedings can provide insight in evaluating the cause of FTT. Discussing a child’s response to food transitions and assessing differences in a child’s food intake outside the home (e.g., at daycare) may provide direction for intervention.

Psychosocial Factors Contributing to Failure to Thrive

A culturally sensitive approach should be used when assessing issues such as food insecurity, domestic violence, caregiver physical and mental health, and family health beliefs. By first framing the relationship between possible stressors in the home environment and FTT, the provider allows for a more open and honest discussion of these issues. The provider can use tools from the validated assessment of household food insecurity and hunger developed by Radimer by assessing responses to statements such as: “I wonder if my food is going to run out ?”

Psychosocial factors may be best assessed through observation of the adult–child interaction demonstrating possible attachment disturbances of a parent not responding to the cues of the child. Observation during a home visit by a clinician or health educator of both food preparation and feeding may be an effective method of ascertaining appropriate preparation, food refusal, and caregiver response. Food insecurity and other aspects of the home environment are also generally best assessed through a home visit.

Organic Causes of Failure to Thrive

Most organic causes of FTT can be detected through thorough histories and physical examinations without laboratory evaluation. The history should include a birth history and birth growth parameters as well as family history, including parental height. Symptoms such as diarrhea, vomiting, respiratory problems, or abnormalities on physical examination should prompt further evaluation. Subtle signs such as atopy may suggest possible food allergies and snoring or mouth breathing may be associated with obstructive sleep apnea. Recurrent infections may be a sign of an immune deficiency and should be evaluated further, but they may also be a sign of the decreased effectiveness of the immune system in a malnourished child. Some conditions can cause or contribute to FTT without apparent signs or symptoms, and if children have no apparent cause for FTT and are not adequately responding to treatment, consideration should be given to testing for those conditions listed in Box 17-1: HIV infection, cystic fibrosis, celiac disease, Giardia and urinary tract infections, and renal tubular acidosis, all of which may cause FTT without other symptoms.

In addition to performing a complete physical examination, a clinician should observe feeding to evaluate for problems with motor coordination leading to difficulty feeding.

Associated Conditions

Children with FTT are at increased risk for developmental problems from iron-deficiency anemia, rickets, and lead poisoning. Children with FTT should have an evaluation of a complete blood count and serum lead level and should be evaluated for rickets.

Management

Children with FTT require frequent follow-up to assess adequacy of weight gain and to assess for new signs or symptoms suggesting organic disease. FTT is often managed in a multidisciplinary outpatient setting that can address the complex factors leading to FTT. The staff may include a pediatrician, speech therapist, nutritionist, and social worker.

Treatment of Underlying Cause

When a specific underlying cause can be identified, treatment of that condition may be the only intervention necessary. There often is impressive catch-up growth after tonsillectomy and adenoidectomy for sleep apnea. Nonorganic causes can be more difficult to treat. However, advocating for children with FTT can lead to weight gain in certain circumstances. Children in families experiencing domestic violence can show dramatic catch-up growth when they are no longer living with the perpetrator or those living in a shelter may gain weight once in their own home.

Treatment of Feeding Difficulties

Caregivers should be counseled to provide food at consistent times, to sit and eat with their children, and to minimize distractions during mealtimes. For toddlers especially, caregivers must make sure that nutritious snacks are offered between meals because toddlers generally consume smaller meals more frequently than older children. Food refusal behaviors such as spitting and throwing food should be ignored. Children benefit from receiving lots of positive attention for accepting food.

Caregivers should be counseled to avoid providing juice and nutritionally deficient food because they can decrease children’s appetite for nutritious food. Marketing, social norms, and individual beliefs can make it difficult for caregivers to appreciate the connection between excess juice intake and poor food intake. The intake of nutritionally dense foods, such as cheese and peanut butter, should be promoted. Foods can be made more nutritionally dense by adding protein powders or fats such as butter, cream, or mayonnaise.

Supplemental Feeds

In early, mild FTT, providing high-calorie foods along with feeding guidance may be sufficient to increase caloric intake to the amount needed for catch-up growth. However, some children do not respond well to feeding interventions. Children may be able to increase intake to levels that are within the normal range for age but are not sufficient for catch-up growth. In these cases, supplemental feedings are needed so children can return to the normal weight range for their age. The benefits of supplemental feedings must be balanced with the risk that they may cause children to decrease their intake of foods and ultimately make it more difficult for them to eat a sufficient amount of typical foods. During infancy, increasing the caloric density of formula above 20 kcal/kg is an effective way of increasing calories without increasing volume. Precision and return demonstration of formula preparation are essential. When caloric density is increased above 24 kcal/kg in young infants, providers and caregivers should watch for signs of diarrhea or dehydration, which can occur with solute overload.

The use of prepared supplemental formulas with caloric densities of 30 kcal/kg can be helpful to increase daily calorie consumption in older children. In children with moderate or severe FTT who are not achieving catch-up growth with oral feeds, placement of a nasogastric tube and ultimately a gastrostomy tube may be necessary. For some children, tube feedings can interfere with oral feeding and cause significant stress for the family. Alternatively, providing calories through tube feedings may be positive for the family by decreasing the stress centered around feeding times.

Hospitalization

Most children with FTT, even those started on tube feedings, can be managed as outpatients. Children with severe FTT require hospitalization for initiation of supplemental feeds to ensure adequate weight gain and monitor for refeeding syndrome. Observation in the hospital may help identify problematic feeding behaviors, although demonstration of adequate weight gain in the hospital does not distinguish between organic and nonorganic causes of FTT.

Social Services

There are several reasons to consider contacting social services in children with FTT. Evaluation for FTT may lead a clinician to suspect child abuse or neglect. Social services intervention may also be required when a child has persistent growth failure and caregivers have not followed through with recommendations for treatment or evaluation despite outreach from clinicians. Finally, in some communities, services such as home visits may only be available if social services are involved.

Future Directions

More research is needed to effectively treat and, ideally, prevent FTT. The effects of food insecurity on children and families is an active area of research. Longitudinal studies would help to determine the long-term outcomes in children with FTT. More research is also needed to demonstrate therapies that significantly improve long-term growth. Research and advocacy related to reducing the effects of poverty on children and the number of children living in poverty could prevent many cases of FTT.

Suggested Readings

Black MM, Dubowitz H, Krishnakumar A, et al. Early intervention and recovery among children with failure to thrive: follow-up at age 8. Pediatrics. 2007;120(1):59-69.

Failure to thrive. In: Kleinman R, editor. Pediatric Nutrition Handbook. ed 6. Elk Grove, IL: American Academy of Pediatrics; 2009:601-636.

Radimer KL, Olson CM, Green JC, et al. Understanding hunger and developing indicators to assess it in women and children. J Nutr Educ. 1992;24(suppl):36S-45S.

Zenel JAJr. Failure to thrive: a general pediatrician’s perspective. Pediatr Rev. 1997;18(11):371-378.

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