Pediatric Failure to

Thrive
Michael Michener, MD
Major, USAF
14 March 2007
 Overview
 Definitions
 Case presentation
 Introduction
 Diagnosis
 Treatment
 Outcomes
 Top 6 things to remember about FTT
 Definition
 Failure to Thrive (FTT):
• Weight below the 5th percentile for age
and sex
• Weight for age curve falls across two
major percentile lines
 Other definitions exist, but are not
superior in predicting problems or
long term outcomes
 Case Presentation
 4 mo F, well child visit
(Sept 06)
• Mom complained about
poor wt gain
• Same problem with first
child
• Husband deployed
• Parents small stature
• Other development was
normal
• Mom alleged that
feeding was going well
(breastfeeding)
• Wt = 10 lb 8 oz
 Case Presentation
WALSTON, KEIRA
02/579-13-8844

 Went to ER at age 5
months
• Wt was “down 1 lb”
• Infant transferred to a
childrens hospital for
inpatient stay
• Infant refusing to breast
or bottle feed
• NG tube placed
• 4oz q4 hours
• OT working with baby to 19-May-06
9-Aug-06 2.73
3.69
4.28
50.80
55.88 39.00

help with feeding

21-Aug-06 3.13 4.68 60.96 41.00
22-Sep-06 4.20 4.85 60.96 41.00
31-Oct-06 5.50 4.88 60.96
2-Nov-06 5.57 4.93 60.96
0.00
0.00
0.00
0.00
 Introduction
 Failure to thrive (FTT):
• A sign that describes a problem rather than a
diagnosis
• Usually describes failure to gain wt
 In more severe cases length and head circumference
can be affected
 Underlying cause is insufficient usable
nutrition to meet the demands for growth
 Approximately 25% of normal children will
have a shift down in their wt curve of up
to 25%, then follow a normal curve -- this
is not failure to thrive
 Introduction
 Specific infant populations-
• Premature/IUGR – wt may be less than
5th percentile, but if following the growth
curve and normal interval growth then
FTT should not be diagnosed
• Modified growth charts exist for specific
populations
 Introduction
 Historically has been divided into organic
and nonorganic causes
• Most cases have mixed etiologies
• This classification system is out of favor
 More useful classification system is:
• Inadequate caloric intake
• Inadequate fat or carbohydrate absorption
• Increased energy requirements
 Etiology
 Inadequate Caloric Intake
• Incorrect preparation of formula
• Poor feeding habits (ex: too much juice)
• Poverty
• Mechanical feeding difficulties (reflux, cleft
palate, oromotor dysfunction)
• Neglect
 Physicians are strongly encouraged to consider child
abuse and neglect in cases of FTT that don’t respond
to appropriate interventions*

*(SOR – C, expert and consensus opinion, Ref 1)

 Etiology
 Inadequate absorption
• Celiac disease
• Cystic fibrosis
• Milk allergy
• Vitamin deficiency
• Biliary Atresia
• Necrotizing enterocolitis
 Etiology
 Increased metabolism
• Hyperthyroidism
• Chronic infection
• Congenital heart disease
• Chronic lung disease

 Other considerations
• Genetic abnormalities, congenital infections,
metabolic disorders (storage diseases, amino
acid disorders)
 Diagnosis
 Accurately plotting growth charts at
every visit is recommended*
 Assess the trends
 H&P more important than labs
• Most cases in primary care setting are
psychosocial or nonorganic in etiology

*(SOR – C, expert and consensus opinion, Ref 1)

 History
 Dietary
 Keep a food diary
 If formula fed, is it being prepared correctly?
 When, where, with whom does the child eat?
 PMH
 Illnesses, hospitalizations, reflux, vomiting, stools?
 Social
 Who lives in the home, family stressors, poverty, drugs?
 Family
 Medical condition (or FTT) in siblings, mental illness,
stature?
 Pregnancy/Birth
 Substance abuse? postpartum depression?
 Physical
 Accurate measurement of child’s
height, weight, head circumference
 Single data point has limited usefulness
 Evaluate for dysmorphic features
 Mouth, palate
 Neurologic exam
• Signs of spasticity or hypotonia
 Cardiovascular/Lung exam
 Physical
 Signs of neglect or abuse
• Lack of age appropriate eye contact, smiling,
vocalization, or interest in environment
• Chronic diaper rash
• Impetigo
• Flat occiput
• Poor hygeine
• Bruises
• Scars
 Physical
 Observe parent-child interactions
• Especially during a feeding session
 How is food or formula prepared?
 Oral motor or swallowing difficulty?
 Is adequate time allowed for feeding?
 Do they cuddle the infant during feeds?
 Is TV or anything else causing a distraction?
 Lab Evaluation
 Unless suggested by H&P, no routine lab
tests recommended initially*
 One study of hospitalized pts resulted in only 1.4%
of tests being of diagnostic assistance in FTT
 If problem persists, could consider:
 CBC, U/A, Electrolytes, TSH, ESR, Lead, HIV, Tb
 If not improving with adequate diet,
consider:
 Stool for fat, reducing substances, pathogens
 Celiac antibody testing
 CF testing

*(SOR – B, historical, uncontrolled study, Ref 1, 2)

 Management
 Goal is “catch-up” weight gain
 Most cases can be managed with nutrition
intervention and/or feeding behavior
modification
 General principles:
• High Calorie Diet
• Close Follow-up
 Keep a prospective feeding diary-72 hour
 Assure access to WIC, food programs, other
community resources
 Management
 Energy intake should be 50% greater
than the basal caloric requirement
 Concentrate formula, add rice cereal to
pureed foods
 Add taste pleasing fats to diet (cheese,
peanut butter, ice cream)
 High calorie milk drinks (Pediasure has 30
cal/oz vs 19 cal per oz in whole milk)
 Multivitamin with iron and zinc
 Limit fruit juice to 8-12 oz per day
 Management
 Parental behavior
• May need reassurance to help with their own
anxiety
• Encourage, but don’t force, child to eat
• Make meals pleasant, regular times, don’t rush
• May need to schedule meals every 2-3 hours
• Make the child comfortable
• Encourage some variety and cover the basic
food groups
• Snacks between meals
 Management
 Do you hospitalize?
• Rarely necessary
• Consider if:
 the child has failed outpt management
 FTT is severe
• Medical emergency if wt <60-70% of ideal wt
• Hypothermia, bradycardia, hypotension
 safety is a concern
 Management
 For difficult cases:
• Multidisciplinary team approach
produces better outcomes
 Dietitians
 Social workers
 Occupational therapists
 Psychologists
• NG tube supplementation may be
necessary
 Outcomes and Prognosis

 Persistent disorders of growth

• 6 of 7 studies showed statistically
significant persistent poor growth (ht,
wt, hc) in FTT group at up to 5 years
from initial treatment.
 Earlier intervention leads to better outcomes
 Outcomes and Prognosis
 FTT and Immunologic/Infectious
Outcomes
• FTT children have significantly increased
susceptibility to infection
 Among hospitalized children – increased
rates of bacteremia and mortality
 Increased rates of upper and lower
respiratory infections
 Outcomes and Prognosis
 Concurrent Behavior disorders
• FTT groups scored lower on reports describing
affect and communications skills
 Behavior disorders at follow-up
• Various trials have demonstrated significant
increase in behavioral problems
 Cognitive Development
• There is a consistent association between FTT
and lower cognitive development test scores in
preschool and primary school children
 Top 6 take home points
1. Evaluation of Failure to Thrive involves
careful H&P, observation of feeding
session, and should not include routine
lab or other diagnostic testing
2. Nutritional deprivation in the infant and
toddler age group can have permanent
effects on growth and brain development
3. Treatment can usually occur by the
primary care physician in the outpatient
setting.
 Top 6 take home points
4. Psychosocial problems predominate as
the causes of FTT in the outpatient
setting
5. Treatment goal is to increase energy
intake to 1.5 times the basal
requirement
6. Earlier intervention may make it easier
to break difficult behavior patterns and
reduce sequelae from malnutrition
 Case Presentation—Follow-up
 Received NG tube WALSTON, KEIRA
02/579-13-8844

feeds for approx 2

weeks
 OT worked with pt
to find a nipple
that she would
take
 Wt gain rapidly
picked up in late 19-May-06
9-Aug-06
21-Aug-06
2.73
3.13
3.69
4.28
4.68
50.80
55.88
60.96
39.00
41.00

November
22-Sep-06 4.20 4.85 60.96 41.00
31-Oct-06 5.50 4.88 60.96
2-Nov-06 5.57 4.93 60.96
7-Nov-06 5.73 4.62
30-Nov-06 6.50 5.13
0.00
0.00
 References
1. Block RW, Krebs NF. Failure to thrive as a manifestation of child neglect.
Pediatrics 2005 Nov; 116(5):1234-7. From National Guidline
Clearinghouse – www.guideline.gov
2. Kirkland, RT. Failure to thrive in children under the age of two. Up to
Date:
http://www.utdol.com/utd/content/topic.do?topicKey=gen_pedi/2884&ty
pe=P&selectedTitle=6~29
version 14.2, april 2006:pgs 1-8.
3. Krugman SD, Dubowitz H. Failure to thrive. American Family Physician,
sept 1 2003. Vol 68 (5).
4. Kane, ML. Pediatric Failure to Thrive. Clinics in Family Practice. Vol 5,
#2, June 2003, pages 293-311.
5. Agency for Healthcare Research and Quality (AHRQ); Evidence report:
Criteria for Determining Disability in Infants and Children: Failure to
thrive. #72, pages 1-54. http://www.ahrq.gov/clinic/
6. Bauchner, H. Failure to thrive, in Behrman: Nelson Textbook of
Pediatrics, 17th ed, chapter 35, 36 - 2004.
7. Rudolf M, Logan S. What is the long term outcome for children who fail
to thrive? A systematic review. In Arch Dis Child 2005;90;925-931.