Poor Weight Gain
Stephen Ludwig
Approach to the Patient with Poor Weight Gain
I. Definition of the Complaint
Poor weight gain, growth failure, and failure to thrive (FTT) are complaints
that involve a vast array of potential causes. At the root of the problem there
may be (a) failure to ingest an appropriate number of calories, (b) failure to
metabolize the ingested food, (c) abnormal loss of calories, or (d) abnormal
need for calories. Whatever the cause, a child
's weight is a sensitive barometer of his or her health. In the case of weight
gain, health must be defined broadly and includes family and psychosocial
causes as well as consideration of disease states. Homer and Ludwig, in a
review of FTT cases, found three broad etiologies: organic, nonorganic, and
mixed.
Organic causes involve a physical condition or disease that leads to failure to
gain weight. Nonorganic causes involve a breakdown in the relationship between
parent and child and the feeding process. Mixed FTT is a condition in which the
child has some organic problem (e.g., gastroesophageal reflux), which, in the
context of the child
's family, becomes a major obstacle to growth, although perhaps another family
would have the capability to manage it. Another scenario for mixed FTT is a
family whose ability to raise a child is marginal, in which the child
's illness brings them into a dysfunctional state.
Many cases of growth failure are diagnostically solved without the need for
hospitalization. But in some cases, either because the growth delay is so
marked or because the child is at a vulnerable age, hospitalization is
required. At times the indication for hospitalization (Table 6-1) is a complex
or obscure problem that requires a more intensive diagnostic evaluation.
II. Complaint by Cause and Frequency
Growth failure is not a diagnosis on its own. It is a symptom whose root cause
must be discovered in order to apply the correct therapies, whether they are
medical, psychosocial, or a combination.
III. Clarifying Questions
• What is the child's pattern of growth over time?
— This question seeks to establish a timing issue. Has this condition existed for
weeks or months? Review of the child
's growth chart created over time is helpful. This information often resides with
the primary care physician.
• What aspects of growth have been affected?
— A comparison of the measurements of weight, length, and head circumference may
provide clues to the etiology. With an acquired condition, the weight is
affected first and most, the length next, and finally the head circumference.
If the condition is congenital, genetic, or endocrinologic, the growth failure
may be more symmetric, or there may be a recognizable pattern of growth
failure.
• Has the child demonstrated any symptoms?
— Are there symptoms of vomiting or diarrhea, indicating loss of nutritional
intake? Are there symptoms of cardiac or pulmonary disease, indicating an
increased requirement for calories or an increased metabolic rate? The history
is much more important than laboratory screening tests in determining the cause
of growth failure.
• What has the child's diet and eating pattern been?
— There is a developmental sequence to the kind of foods given to a child and the
way they are presented. For example, toward the end of the first year, children
typically want to eat some table foods and to manipulate the foods into their
own mouths. A parent who insists in giving strained foods by parenteral
spoon-feeding at this stage may find their child resistant and therefore
failing to gain weight. It may be instructive to watch a feeding encounter or
mealtime to get a sense of the process. Mealtime may be pleasurable for child
and parent or an exercise in frustration and stress for both.
• What is the state of the family unit and their lifestyle?
— This question gets at the many psychosocial causes of growth failure. Is this
family functioning in other ways? Are there support systems for the parents?
Often it is helpful to ask the parent to review a typical day. Some families
have a well-traveled pathway through each day. For other families, each day is
a new adventure from beginning to end. Just as there is a differential
diagnosis for organic causes of growth failure (Table 6-2), there are a host of
nonorganic causes (Table 6-3), including problems relating to the parents
(e.g., postpartum depression) and problems with the entire family system (e.g.,
substance abuse).
IV. References
1. Miller LA, Grunwald GK, Johnson SL, et al. Disease severity at time of
referral for pediatric failure to thrive and obesity: time for a paradigm
shift?
J Pediatr 2002;141:121–124.
2. Schwartz ID. Failure to thrive: an old nemesis in the new millennium. Pediatr Rev 2000;21:257–264.
3. Shah MD. Failure to thrive in children. J Clin Gastroenterol 2002;35:371–374.
4. Gordon EF, Vasquez DM. Failure to thrive: an expanded conceptual method. In:
Drotar D, ed.
New directions in failure to thrive. New York: Plenum Press, 1986:69.
5. Homer C, Ludwig S. Categorization of etiology for failure to thrive. Am J Dis Child 1981;135:848–851.
6. Bithoney WG, Dubowitz H, Egan H. Failure to thrive/growth deficiency. Pediatr Rev 1992;13:453–460.
7. Zenel JA. Failure to thrive: a general pediatrician's perspective. Pediatr Rev 1997;18:371–378.
The following cases represent less common causes of poor weight gain or FTT in
children.
Pictures
Book Source Details
- Book Title: Pediatric Complaints and Diagnostic Dilemmas
- Author(s): Samir S Shah MD; Stephen Ludwig MD
- Year of Publication: 2003
- Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2008 Williams & Wilkins.
More About Causes of Weight gain
» Next page: Poor Weight Gain - Case 6-1: 16-Month-Old Boy (Pediatric Complaints and Diagnostic Dilemmas)
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