Do not perform an extensivelaboratory or radiographic evaluation for failure to thrive (FTT)
Do not perform an extensivelaboratory or radiographic evaluation for failure to thrive (FTT): Excerpt from Avoiding Common Pediatric Errors
Author:
Michael Clemmens, MD
What to Do - Gather Appropriate Data
FTT is a common pediatric problem, especially during infancy. The diagnosis of FTT is made when a child's weight is less than the fifth percentile for
weight-for-age or crosses two major percentile lines. Identifying the underlying cause of FTT is usually straightforward, but occasionally it requires an
inpatient evaluation. The most important tools for determining the underlying cause of poor growth are athorough history, complete physical exam, and
a staged laboratory workup. There are few other areas in pediatrics where
the history is so vitally important. Less often, the exam will hold a clue to
the etiology. When the history and physical do not reveal the diagnosis, the
laboratory evaluation is not likely to prove helpful. In some cases, carefully
selected testing is still in order.
Traditionally, FTT has been classified as organic or nonorganic, although there is often considerable overlap. Many children will have mixed
etiologies for their poor growth. Organic FTT reflects an underlying pathophysiologic abnormality, resulting in an inability to ingest, absorb, or utilize
adequate nutrition to sustain normal growth. Conditions associated with
increased metabolic demands may make the standard caloric intake inadequate. Examples of organic FTT include swallowing disorders, malabsorption, metabolic disorders, and congestive heart failure.
The great majority of FTT is nonorganic and occurs when an otherwise healthy child does not get enough nutrition to sustain normal growth.
Difficulties with breastfeeding, caregiver misunderstanding about infant nutritional needs, and improper mixing of formula are three common examples
of nonorganic FTT. Often, there are psychosocial factors, such as financial
stress or caregiver mental illness, influencing the situation. Most patients
with nonorganic FTT are treated successfully as outpatients.
A detailed history is the most powerful diagnostic tool for determining
the cause of a child's FTT. Special attention to the nutritional and psychosocial history is paramount. The provider must take the time to learn about
the child's diet and feeding behaviors, the caregiver's understanding of the
child's nutritional needs, and the entire family's social situation. A skilled
social worker may be able to contribute significantly to this process.
In addition, because abnormalities in any organ system can lead to
FTT,athoroughphysicalexamshouldbeperformed.Allgrowthparameters
should be measured, plotted, and compared to prior data points. Other key
elements of the exam include identification of dysmorphic features, signs of
physical abuse or neglect, and possible effects of malnutrition. Observing
the interaction between the child and caregiver may provide important clues
to the psychosocial factors influencing the situation.
If the cause of FTT is not clear after a thorough history and physical
exam, a 3-day diet diary and calorie count can provide critical information.
Inadequate caloric intake is the most common cause of FTT. Screening laboratory and radiographic tests are helpful in only approximately 5% of cases.
A directed laboratory or radiographic evaluation, guided by the findings on
the history or physical exam, is more likely to be useful.
The major pitfall in the evaluation of a child with FTT is performing
an inadequate history and physical examination. Most cases of FTT can be
treated successfully as an outpatient. Often, a multidisciplinary approach,
including social services and referral to a nutritionist, is useful. However,
hospitalization is indicated if an accurate dietary history cannot be determined, if a trial of increased caloric intake in the home environment fails,
if there are concerns about the safety of the home environment, or if an
underlying pathologic process is identified.
Suggested Readings
Berwick DM. Nonorganic failure to thrive. Pediatr Rev. 1980;1:265–279.
Bithoney WG, Dubowitz H, Egan H. Failure to thrive/growth deficiency. Pediatr Rev. 1992;
13:453–460.
Krugman SD, Dubowitz H. Failure to thrive. Am Fam Physician. 2003;68:879–884.
Sills RH. Failure to thrive. The role of clinical and laboratory evaluation. Am J Dis Child. 1978;
132:967–969.
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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Failure to Thrive (The 5-Minute Pediatric Consult)
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