Failure to Thrive

Failure to Thrive: Excerpt from In A Page: Pediatric Signs and Symptoms

Failure to thrive (FTT) is a common problem accounting for 1–5% of referrals to pediatric centers. Although no consensus exists, FTT applies to children under 2 years of age whose weight is less than 5% on two occasions or crosses two major growth percentiles. It is more common among children in poverty. The causes can be broken down into three categories: decreased caloric intake, decreased caloric absorption, and increased caloric needs.

Differential Diagnosis

• Psychosocial (non-organic)
  –Insufficient caloric intake
  –Most common etiology
  –Cause accounts for 1/3–1/2 of cases investigated in tertiary settings
• Gastrointestinal disorders
  –Gastroesophageal reflux
  –Celiac disease
  –Milk protein allergy
  –Pancreatic insufficiency
  –Inflammatory bowel disease
• Endocrine disorders
  –Hypothyroidism
  –Hyperthyroidism
  –Diabetes mellitus
  –Diabetes insipidus
  –Growth hormone deficiency
• Cardiac disorders
  –Congestive heart failure
  –Congenital anomalies
• Pulmonary disorders
  –Brochopulmonary dysplasia
  –Asthma
  –Cystic fibrosis
• Infectious
  –HIV
  –Parasites
  –Tuberculosis
• Neurologic
  –Hypotonia
  –Cerebral hemorrhage
  –Diencephalic syndrome
• Metabolic
  –Galactosemia
  –Methylmalonic acidemia
  –Tyrosinemia
• Renal
  –Renal tubular acidosis
  –Chronic urinary tract infections
  –Chronic renal insufficiency
• Syndromes
  –Down syndrome
  –Turner syndrome
  –Russell-Silver dwarfism
  –Fetal alcohol syndrome
• Anatomic
  –Cleft lip/palate
  –Malrotation
  –Pyloric stenosis
• Lead poisoning

Workup and Diagnosis

• History
  –Emesis, number and quality of stools, excessive energy, diaphoresis, breathing difficulties, urinary frequency
  –Diet history: Duration and quantity of feeding, food preferences, juice intake, food allergies
  –Medical history: Chronic medical problems, surgeries
  –Observation: Eye contact, absence of smile, lack of interest in environment, parental interaction
  –Psychosocial history: Caretakers, financial status, employment, family stress, poverty indicators, support systems, parental age, substance abuse
• Birth history
  –Growth retardation, low birth weight, intrauterine stress, prematurity, parental substance abuse

• Physical exam
  –Accurate height, weight, and head circumference, multiple points on growth curve
  –Neuro/developmental age (milestones)
  –Murmurs, wheezes/crackles, abdominal masses
  –Exam of hard/soft palate, dysmorphic features
  –Signs of neglect/abuse including poor hygiene persistent diaper rash, bruising, unexplained scars

• Initial lab screen to include CBC, electrolytes, urinalysis
  –Consider thyroid function tests, HIV testing, TB skin testing, celiac testing (anti-tissue transglutaminase)
• Radiographs/imaging only if history dictates
• Diet journal, 3-day calorie counts

Treatment

• Hospitalization unnecessary unless severe malnutrition or abuse
• Psychosocial causes require team approach with physician, family, social worker, dieticians
• Goal of refeeding to allow for catch-up growth at 1.25–1.5 times normal caloric intake for age
  –Monitor for refeeding syndrome with electrolyte imbalances (e.g., phosphorus, potassium, glucose)
• Structured and scheduled feeding crucial in appropriate feeding atmosphere
• Consider nasogastric feedings if weight gain by other methods is insufficient within 4–6 weeks
• Treat organic causes
  –Diet restriction for food allergy, metabolic disease
  –Correct electrolyte disturbances
  –Treat endocrine disease
  –Remove environmental exposures

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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