Practice Essentials
Failure to thrive (FTT), also referred to as "weight faltering," "faltering growth," or "growth deficit," [1] is the result of either inadequate calorie absorption, excessive calorie expenditure, or inadequate intake of calories (see image below). [2] It is not usually a result of neglect. [3]
This 6-month-old infant was admitted with marasmus. The infant was born to a mother who did not bond effectively because of postpartum depression. He has evidence of severe wasting and neglectful care as also evidenced by the diaper excoriation. Weight gain was achieved by placement in foster home.
Signs and symptoms
Physical examination most often reveals a rather small and undernourished infant with normal vital signs and with most developmental milestones either intact or mildly delayed.
Diagnosis
The diagnosis is based on growth parameters that show consistent decrease in growth velocity over time. Prior focus had been on weight that has fallen over 2 or more percentiles or growth persistently below the third or fifth percentiles if no underlying cause or comorbidity, such as prematurity, is identified. A z-score comparing the patient’s growth measurements with the means of a similar population is now standard practice. The World Health Organization (WHO) definines growth faltering as a fall in weight for age (WFA) z-score of ≥ 1.0. [4]
The physical examination must be detailed and carefully performed to detect any disease or syndrome that might affect growth and development. A detailed history of food intake from infancy through the current period is vital.
Initial and follow-up newborn screening tests, as follows:
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CBC count - WBC and RBC indices for possible indication of occult infection, microcytic or hemolytic anemias, or immune deficiency
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Urinalysis and culture - Hydration status (if warranted) with specific gravity, evidence of infection, renal tubular acidosis
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Renal function - Serum electrolytes, BUN, and creatinine levels
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Liver function - Liver function tests considered in children with signs of protein wasting or organomegaly
Additional testing as needed or indicated, as follows:
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Human immunodeficiency virus (HIV) testing if risk factors are noted or if history and examination are at all suggestive
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Sweat test for cystic fibrosis
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Testing for malabsorption may be recommended by a GI consultant
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Zinc level reported to be low in malnourished infants and children
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Metabolic and endocrinology screening (only as needed)
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Tuberculosis testing
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Stool studies
Management
FTT is considered a medical emergency in infants or toddlers who weigh less than 70% of the predicted weight for length. Most infants and children younger than 1–2 years can be treated with a coordinated outpatient care plan.
Nutritional treatment is based on aggressive feeding to prevent cognitive loss. Most children require 100–120 kcal/kg/day, but this may be increased to achieve catch-up weight gain that is greater than normal. Feeding regimen may need to be adjusted if there is a concern for refeeding syndrome.
Nasogastric and gastrostomy tubes should be reserved for the most severe cases.
Background
Although the discussion of pediatric growth failure can be traced back over a century in the medical literature, the term failure to thrive (FTT) has only been used in the past several decades. However, this term is now considered ambiguous and potentially stigmatizing, and thus, there has been a shift towards using "weight faltering," "faltering growth," or "growth deficit." [1] Faltering growth is not usually a result of neglect. [3] Faltering growth in children is diagnosed based on anthropometrical indicators, with weight gain as the predominant choice of indicator and cut-off around the 5th percentile. [5] The previously used dichotomy of nonorganic (environmentally related) and organic growth failure is the result of either inadequate calorie absorption, excessive calorie expenditure, or inadequate intake of calories. [2] See the image below.
This 6-month-old infant was admitted with marasmus. The infant was born to a mother who did not bond effectively because of postpartum depression. He has evidence of severe wasting and neglectful care as also evidenced by the diaper excoriation. Weight gain was achieved by placement in foster home.
The objective parameter is usually the deceleration of growth height and weight. [5] If FTT is severe, the parameter is poor brain growth as evidenced by head circumference. The diagnosis is based on growth parameters that (1) fall over 2 or more percentiles, (2) are persistently below the third or fifth percentiles, or (3) are less than the 80th percentile of median weight for height measurement. Growth failure is now generally accepted to be overly simplistic and obsolete.
A good working definition of growth failure related to aberrant caregiving is the failure to maintain an established pattern of growth and development that responds to the provision of adequate nutritional and emotional needs of the patient. Most cases of FTT are not related to neglectful caregiving, although it may be a sign of maltreatment and should be considered during an evaluation for growth failure. [6] A joint clinical report by the American Academy of Pediatrics Committee on Child Abuse and Neglect and the American Academy of Pediatrics Committee on Nutrition outlines 3 indicators of neglect: “Intentional withholding of food from the child; strong beliefs in health and/or nutrition regimens that jeopardize a child’s well-being; and family that is resistant to recommended interventions despite a multidisciplinary team approach.” [7]
Epidemiology
Frequency
Incidence of true growth failure of children in the United States is not accurately known. [8] However, nearly 20% of children younger than 4 years live in poverty, and the inability to obtain adequate food is directly related to such conditions.
International problems of poverty and hunger occur in many nations. The death rate from malnutrition and infection for these countries can be high. [9]
Mortality/morbidity
The morbidity of malnutrition as a separate clinical entity is discussed in Malnutrition. Malnutrition that accompanies faltering growth can lead to significant developmental delays in children. The first 2 years of a child’s life are a sensitive period of rapid brain growth when neurodevelopmental outcomes can be influenced. Motor, fine motor, speech, language, and cognitive delays have been documented. [10] The resultant poor cognitive ability can lead to emotional and behavioral problems as well. Children die each year in the United States from malnutrition; some severe cases are directly related to intentional child neglect.
Demographics
No racial predilection is noted because growth failure related to aberrant caregiving can affect people of all races.
No sex predilection is important to note.
Growth failure for this discussion is described in children from infancy through the toddler period.
Prognosis
Early diagnosis of failure to thrive (FTT)/faltering growth is crucial. Growth, development and behavior can be affected. [10]
Prognosis should be guarded for infants and children with severe malnutrition. If abuse and neglect are comorbid in a case of FTT/faltering growth, the degree of risk and risk factors for poor outcome increase in complexity and potential for poor outcome increases.
With early intervention and treatment, the overall outcome can be promising for infants and children who respond to the nutritional and environmental interventions needed. Nutritional and growth improvement alone does not mean that all problems are resolved.
Patient Education
Patient education is one of the most crucial elements of the care plan for infants and children with faltering growth. It involves education dealing with nutrition, feeding, and normal child behavior and development.
Also shared with caregivers are the interventions and therapy needed for the patient and those needed to address the family or caregiver pathology or dysfunction.
Consider such education a long-term requirement throughout the early years of the child's growth and, in some situations, for the entire childhood.
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This 6-month-old infant was admitted with marasmus. The infant was born to a mother who did not bond effectively because of postpartum depression. He has evidence of severe wasting and neglectful care as also evidenced by the diaper excoriation. Weight gain was achieved by placement in foster home.
