Failure to thrive

Dr Andrew describes a Systematic Approach to the Child Who “Doesn’t Grow”

Failure to thrive (FTT), is a term used in pediatric medicine, most commonly to describe a failure to gain weight, but some providers have also used it to describe a failure to grow, or a failure to grow and to gain weight. As used by pediatricians, it covers poor physical growth of any cause.

Failure to thrive is associated with abnormal or arrested physical growth and development in which height and weight measurements fall below the third percentile, or over a period of time cross percentiles from an original baseline.

Scope of the Problem

1% of all pediatric hospitalizations are related to FTT

• Possible sequelae
• Chronic growth disorders
• Psychological dysfunction, for example attention disorders, poor peer relationships
• Cognitive dysfunction, for example language and reading deficits
• Language and reading problems

Diagnosis of Failure to Thrive

FTT is typically diagnosed with reference to “Growth chart criteria” and / or based on the failure of somatic growth in first two years.

Growth charts consist of a series of percentile curves that illustrate the distribution of selected body measurements in children. Pediatric growth charts have been used by pediatricians, nurses, and parents to track the growth of infants, children, and adolescents in the United States since the seventies. It is important to use up-to-date growth charts and charts relevant to the population with which one is dealing.

The following table is from McLaren and Reed, 1970 using body weight as a measure of protein-calorie malnutrition (PCM) in the child with nutritional FTT.

Classification	% of ideal *
Normal	90-110
Mild PCM	85-80
Moderate PCM	75-85
Severe PCM	<75

* weight as a percentage of ideal for actual height

Formal diagnostic criteria consist of: falling below 3^rd percentile in height, weight and head circumference (or crossing two major percentile lines in less than six months, even though weight is >3^rd percentile, failure of somatic growth in first two years, failure to achieve developmental milestones at appropriate times or loss of skills previously acquired.

Classification of FTT causes

10-15% of FTT cases are found to be “Organic”, or due to disease or deficiency. The majority of cases are “Non-organic” or a combination of organic and non-organic etiologies. Initial presentation beyond the age of 12 months supports the more likely possibility of a non-organic cause.

Organic FTT

There are many medical causes of failure to thrive. These include:

• Kidney disease
• Immune disorders/AIDS
• Leukemia/other malignancy
• Heart disease
• Cystic fibrosis
• Malabsorption
• Allergies/asthma
• Thyroid disorders
• Diabetes mellitus
• Growth hormone deficiency

Non-organic FTT

Factors in the child’s environment, such as abuse or neglect, can be a cause of FTT, including:

• Food is unavailable
  • Poverty
  • Food money diverted to other areas
  • Willful neglect
• Poor maternal-child interaction
  • Diminished maternal cognitive ability
  • Mental illness, e.g. depression, adverse childhood experiences of parent(s)
  • Inadequate family supports/social isolation
  • Domestic violence
  • Poor maternal physical health
  • Rigid, unrealistic expectations of the child
• Maternal substance abuse
• Maternal eating disorder
• Peculiar food beliefs
• Social chaos
• Behaviorally difficult children
• Neurologically impaired children

Diagnostic Evaluation of FTT

The diagnostic evaluation of the child with FTT is a multidisciplinary effort, involving the though examination of the child’s birth, medical and family history, birth, and subsequent growth and current physical condition.

History

• Environmental, family and social
• Apparent allergies
• Diet/Nutrition, including apparent food intolerance
• Chronic vomiting and/or diarrhea
• Chronic cough
• Seizures
• Developmental milestones

Physical Examination

• General – the neglected child may . . .
  • Be very passive and compliant]
  • Not cry (“trained not to cry”)
  • Love everyone indiscriminately
  • Love no one indiscriminately
• Skin – both organic and non-organic etiologies may be manifest in the skin
  • Severe cradle cap and/or diaper rash, skin infections or other hygiene issues
  • Bruises, burns
  • Neurofibromas, café-au-lait spots
  • Thin skin, fine hair (hypothyroid)
  • Eczema
  • Pigmented nevi (Turner’s syndrome)
  • Jaundice, cyanosis, pallor
• Head
  • Craniotabes (rickets)
  • Hair distribution, quality
  • Micro- or macrocephaly
  • Dysmorphic features
  • Percussion of sinuses
• Eyes, ears, nose
  • Conjunctiva and sclerae – pale, anemic, icteric, telangiectasia, blue sclerae
  • Speckled iris (Trisomy 21)
  • Nystagmus
  • Fundus/retina
  • Otitis media
  • Auricular ectopia, deformity
  • Drainage (purulent, serous, CSF)
  • Hearing
  • Allergic rhinitis
  • Persistent drainage
  • Deformity
• Mouth and throat
  • Cleft palate
  • Teeth (including level of maturation), gingival, mucous membrane lesions
  • Tonsillar inflammation, enlargement
  • Halitosis (bronchiectasis)
• Neck
  • Webbing
  • Thyroid enlargement or nodule(s)
• Respiratory
  • Persistent URI
  • Recurrent pneumonia
  • Wheezing
  • Irregular respiratory pattern
• Cardiovascular
  • Murmur
  • Signs of congestive failure
  • Pulses
• Abdomen
  • Distention
  • Enlargement or masses of liver or spleen
• Genitourinary
  • Small gonads
  • Enlarged clitoris, labia
  • Cryptorchidism
  • Micropenis
• Extremities
  • Cyanosis, clubbing, edema
  • Simian crease, syndactyly, polydactyly
  • Spinal deformity
  • Joints for infection, mobility
• Neurological
  • Hypotonia, poor reflexes
  • Hypertonia, exaggerated reflexes
  • Seizures
  • Speech, gait
  • Sensorium
  • Odd behaviors
    • Intense watchfulness
    • Inappropriate stranger anxiety
    • Diminished vocalizations
    • Unusual postures or motor movements

Once the initial history and physical have been completed, the real work begins on zeroing in on a diagnosis. The H&P should make known or at least suggest issues that may require expeditious confirmation by ancillary studies and development of a treatment plan. More often in FTT the work-up is just beginning.

Detailed Diagnostic Evaluation

Birth history should be obtained in a comprehensive and sensitive manner. Important information includes:

• Complications of pregnancy
  • Toxemia
  • Bleeding
  • Intercurrent infection (TORCHES)
  • Premature rupture of membranes
• Prematurity
• Anxiolytic therapy of mother during pregnancy
• Unwanted, unplanned pregnancy
• Undesired gender
• “Damaged” or “defective” child

Growth history means just that, not just the current height and weight but procurement and graphing of all existing growth data.

Environmental, family and social history should include the following:

• Height and weight of parents
• Spacing of children, birth order (increased incidence of FTT in youngest child)
• FTT in siblings
• Recent death of parent, sibling or other family member
• Marital stability/domestic violence
• Recent move
• Hereditary diseases, mental retardation, allergic disorders

A three-day diet recall and diet history guided by a certified dietician or nutritionist is ideal, accompanied by the following dietary history issues:

• Food intolerance?
• Strong likes or dislikes?
• Vitamins? – Hypervitaminosis A and D may cause FTT

Accuracy is essential, i.e. number of feedings, volume of feedings, type and form of formula, how are the feedings prepared?

Developmental history at this stage should include a more detailed and formalized evaluation of milestones (with corroboration), evidence of loss of previously acquired skills and demonstrable development of social skills.

Resources permitting, a potentially critical component of the evaluation of FTT is the home visit. It is during this time a trained professional can directly observe at least one feeding and asses some of the following parameters:

• Pets
• Water source
• Composition of household
• Surrounding neighborhood – other children?
• Frequent visitors?
• Peeling paint, lead exposure
• Inadequate sanitation
• Pest infestation
• Inadequate heating, lighting, water

Laboratory testing must be directed by the clinical history and physical examination. In the absence of a suspicion of a chronic disease, the yield of an extensive laboratory workup is essentially zero, representing a misuse of resources. It is the history and physical, not the laboratory investigation, that should be comprehensive. The latter is ancillary/confirmatory. A case may be made for including the following studies as “routine:”

• Complete blood count with differential and examination of peripheral smear
• Basic blood chemistries (sodium, potassium, chloride, carbon dioxide, calcium, phosphorus, pH
• Urinalysis (with culture if indicated)
• CXR
• Stool examination

Only if indicated by the comprehensive history and physical should one or more of the following be pursued:

• T₄, TSH
• Bone age
• Long bone films for fractures, lead lines, primary bone disorders
• GI series
• Skull films, C/T brain
• Bone scan
• Abdominal ultrasound
• EKG
• Echocardiogram
• EEG
• Buccal smear, chromosomal analysis
• Sweat chloride
• Additional blood chemistries – total protein, albumin, glucose, alkaline phosphatase, liver functions, LDH, total and direct bilirubin, lipids
• Sed rate
• Serum protein electrophoresis
• Heavy metal screen
• Endocrine studies
• Glucose tolerance test
• Skin tests
• Urine for amino acids
• Tests for malabsorption of fats and/or carbohydrates

Social Services Assessment

• Medical risk factors
• Family risk factors
• Social risk factors
• Psychological risk factors
• Family strengths/resources

Treatment

• Medical therapy as indicated for any underlying medical condition
• Therapeutic day care – weight gain of 45 gm/day for two weeks or 60gm/day for one week is diagnostic of caloric deprivation
• Nutritional supplementation
• Ongoing nutritional consulting and monitoring
  • Address poor feeding technique and other ineffective parenting
  • Improved structure and content of mealtime
• Referrals/consultations
• Address underlying social issues
• Psychotherapy for mother &/or family
• Addiction counseling as indicated
• Foster care if necessary nature and severity of case warrants placement outside the home.

Summary

The pediatric health care provider is commonly faced with the infant or young child whose growth parameters raise some level of concern. A methodical, systematic diagnostic approach is essential in ferreting out potentially treatable medical conditions. Even if a medical diagnosis is reached, most cases have a significant element of non-organic factors contributing to the child’s failure to thrive. Tragically, neglect is the most common type of child abuse and more children die from neglect than any other form of abuse. This makes the routine assessment of growth and development an essential feature of every well child care visit. In the event of  failure to thrive due to nutritional neglect, failure to document physical growth and other markers of child development may prevent an accurate diagnosis and make it impossible to protect a child, provide useful intervention or prove the diagnosis beyond a reasonable in the event of a fatality.