FAILURE TO THRIVE

I. Definition

  1. Failure to gain weight in kids < 3yo; more severe cases may affect height and head circumference also
  1. Weight < 3 %ile OR
  2. Weight < 80% of ideal weight OR
  3. Weight plateauing/decreasing while crossing 2 percentile lines on growth chart (most accurate because addresses growth velocity and has cross-ethnic applications)
  1. Definitions of normal growth (source: National Research Council Food & Nutrition Board):
Age Median Daily Weight Gain RDA in kCal/kg/d
0-3mos 26-31g 108
3-6mos 17-18g 108
6-9mos 12-13g 98
9-12mos 9g 98
1-3y 7-9g 102
4-6y About 6g 90
  1. Us. mixed medical and psychosocial etiology
  2. An important problem esp. in infancy because of "nutritional vulnerability," i.e. can interfere with nl. growth and development

II. Epidemiology

  1. Equal sex and race incidence
  2. 1% of all pediatric hospitalizations
  3. 10% of kids in rural primary care setting
  4. 10% of kids with FTT are homeless

III. Etiology: every serious medical disease and/or psychosocial disruption may present as FTT

  1. Organic (< 20% of cases)
  1. Malnutrition/inadequate intake
  1. Inadequate breast milk production
  1. Malabsorption including celiac disease
  2. Chronic disease
  3. Prenatal onset growth deficiency with delayed postnatal growth velocity
  4. GI (40% of organic): clefts, chalasia, GERD, celiac disease, IBD, Hirshsprung's, CF, liver disease
  5. Renal including RTA (may be occult in early stages)
  6. CNS (20% of organic)
  7. Endocrine: DM, DI, thyroid, adrenal, pituitary
  8. Cardiac including EFE (may be occult in early stages)
  1. Non-organic
  1. Most commonly occurs age 6-12 mos
  2. Increased family stress with disorganized feeding interations
  1. Mixed
  1. Recurrent acute illnesses (otitis, asthma) can lead to altered parental interactions, variable eating behavior, and decreased growth velocity
  2. Inadequate caloric intake due to poor feeding technique, chaotic household, neglect/abuse or emotional deprivation
  1. Common causes by age group
  1. IUGR
  1. Prenatal infections
  2. Congenital syndromes
  3. Teratogens
  1. 0-3 mos
  1. Incorrect formula preparation
  2. Failed breastfeeding
  3. Neglect
  4. Poor feeding interations
  5. Metabolic, chromosomal, or anatomic abnormality
  1. 3-6 mos
  1. Incorrect formula preparation
  2. Underfeeding, poss. due to poverty
  3. Milk protein intolerance
  4. Oral-motor dysfunction
  5. GERD
  6. Celiac disease, AIDS, cystic fibrosis, congenital heart disease
  1. 7-12 mos
  1. Autonomy struggles
  2. "Overly fastidious parent" (?)
  3. Oral-motor dysfunction
  4. Delayed introduction of solids
  5. Intolerance of new foods
  1. > 12 mos
  1. Coercive feeding
  2. Highly distractible child/distracting environment
  3. New psychosocial stressor
  4. Other illness

IV. Evaluation

  1. Hx and Px should point the way to need for w/u for organic causes
  2. Hx
  1. Perinatal with particular attention to prenatal onset growth deficiency and newborn screening labs
  2. PMHx inc. previous/recurrent illnesses and immunizations
  3. Diet hx
  1. Quantity and requency of feedings
  2. How prepared
  3. 3 day diet hx for older kids
  4. Feeding difficulties inc. choking, regurgitation
  5. Parent-child struggles at mealtime
  1. Sleep, bowel, bladder habits
  2. Developmental assessment
  3. Family hx inc. growth parameters of siblings, parents, and grandparents
  4. Social hx. inc. assessment of caretakers, family stress, financial situation, planned pregnancy, availability of 2 parents, support system, drugs/EtOH in home, etc.
  1. Px
  1. OFC, Ht, Wt; double-check plotting on growth curve
  1. Ht, Wt, OFC all < 3 %ile: severe FTT or prenatal onset growth deficiency
  2. Wt, Ht < 3 %ile; OFC nl: endocrinopathy, structural dystrophies, constitutional short stature
  3. Wt < 3 %ile, OFC and Ht nl: inadequate calories (diminished intake, absorption, decreased or increased utilization); environmental deprivation
  1. General appearance, muscle mass, affect, parental interation
  2. Signs of abuse or neglect, inc. trauma, flat and/or balding occiput
  3. Signs of other system compromise:
  1. GI: protruberant abdomen, organomegaly
  2. Cardiac: murmur, signs of CHF
  3. CNS: cranial abnormalities or other focal findings

V. Further w/u and managment

  1. Hospitalization if evidence of abuse or treatable organic disease
  2. Feeding trial, daily weights, strict I/O
  1. Resumption of weight gain may take 1-2 weeks even with adequate calories
  2. Will require more calories for "catch-up" growth, e.g. 150% of requirement calculated for the ideal weight for height
  3. Begin with PO feedings, often with enriched formula (24-27 kCal/oz) or "Polycose" of MCT oil for older kids
  1. Inpt evaluation should include repeat multidisciplinary approach of possible organic and environmental etiologies as indicated
  2. Should also involve parents if appropriate & include adequate stimulation of pt
  3. Initial lab eval (often done during outpt w/u); n.b. labs establish diagnosis in only 0.4% of cases in one study!
  1. CBC, lytes, BUN, Cr, glucose
  2. Total protein, albumin, serum carotene (if adequate carotene intake by hx)
  3. u/a, c & s
  4. Stool for pH, reducing substances, qualitative fat
  5. Consider CXR, sweat chloride, thyroid functions, bone age, growth hormone, endomysial Ag and anti-andomysial antigen IgA (to screen for celiac disease), or other tests as suggested by Hx/Px

VI. Pearls

  1. Double-check age, measurements, plotting on growth chart!
  2. Pay attention to growth velocity and trends. Some children grow in spurts!
  3. Infants who are large at birth may "find their growth curves" age 6-15 mos, and establish new velocity
  4. With IUGR, may have decreased postnatal growth velocity. If catch-up growth is going to occur, should begin by age 3y

VII. Long-term prognosis: many remain small and 50% have developmental/educational difficulties or personality disorders; only 33% are ultimately "normal"

(Source: B. Oldham lecture, 5/96)