eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Child Abuse & Neglect: Failure to Thrive: Differential Diagnoses & Workup

Author: Andrew P Sirotnak, MD, Department Head, Child Abuse and Neglect, Director, Kempe Child Protection Team
Coauthor(s): Antonia Chiesa, MD, Senior Instructor of Pediatrics, University of Colorado at Denver Health Sciences Center
Contributor Information and Disclosures

Updated: Jul 14, 2008

Differential Diagnoses

Child Abuse & Neglect: Physical Abuse
Cystic Fibrosis
Gastroesophageal Reflux
Growth Failure
Growth Hormone Deficiency
Human Immunodeficiency Virus Infection

Other Problems to Be Considered

Munchausen syndrome by proxy
Inborn error of metabolism and metabolic disease
Other endocrine disorder (thyroid disease, diabetes mellitus)
Genetic disorder
Malabsorption
Formula intolerance or allergy
Renal tubular acidosis
Congenital heart defect

Infants who are premature and who have had complications in the newborn period are at risk for growth failure. Premature infants who have intensive care needs at home are at greater risk for neglect or abuse.

Workup

Laboratory Studies

The history and physical examination should guide any laboratory or ancillary testing. Most infants and children with growth failure related to environmental factors need very limited laboratory screenings. In the young infant or child, a few prudent baseline tests maybe indicated.

  • Initial and follow-up newborn screening tests
    • CBC count - WBC and RBC indices for possible indication of occult infection, microcytic or hemolytic anemias, or immune deficiency
    • Urinalysis and culture - Hydration status (if warranted) with specific gravity, evidence of infection, renal tubular acidosis
    • Renal function - Serum electrolytes, BUN, and creatinine levels
    • Liver function - Liver function tests considered in children with signs of protein wasting or organomegaly
  • Additional testing as needed or indicated
    • Human immunodeficiency virus (HIV) testing if risk factors are noted or if history and examination are at all suggestive
    • Sweat test for cystic fibrosis
    • Zinc level reported to be low in malnourished infants and children
    • Metabolic and endocrinology screening (only as needed)
    • Tuberculosis testing
    • Stool studies

Imaging Studies

  • Imaging studies are not routinely needed.
  • Perform skeletal survey for occult trauma if physical abuse is suspected or signs are present upon examination.
  • Head CT scanning or MRI studies are indicated if examination reveals microcephaly, macrocephaly, or congenital malformation or if abusive head trauma is a concern.
  • Perform bone age studies of wrists in children who have constitutionally short stature or are extremely malnourished; in patients in whom bone density or ricks is a concern, perform knee studies, wrist studies, or both.

Other Tests

  • Most other tests are not indicated unless a specific disease process is suspected that warrants investigation.

Procedures

  • Most other procedures, invasive or not, are not indicated unless a specific disease process is suspected that warrants investigation.

More on Child Abuse & Neglect: Failure to Thrive

Overview: Child Abuse & Neglect: Failure to Thrive
Differential Diagnoses & Workup: Child Abuse & Neglect: Failure to Thrive
Treatment & Medication: Child Abuse & Neglect: Failure to Thrive
Follow-up: Child Abuse & Neglect: Failure to Thrive
Multimedia: Child Abuse & Neglect: Failure to Thrive
References
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References

  1. Black MM, Dubowitz H, Casey PH, et al. Failure to thrive as distinct from child neglect. Pediatrics. Apr 2006;117(4):1456-8; author reply 1458-9. [Medline].

  2. Block RW, Krebs NF, American Academy of Pediatrics Committee on Child Abuse and Neglect, American Academy of Pediatrics Committee on Nutrition. Failure to thrive as a manifestation of child neglect. Pediatrics. Nov 2005;116(5):1234-7. [Medline].

  3. Bambang S, Spencer NJ, Logan S, Gill L. Cause-specific perinatal death rates, birth weight and deprivation in the West Midlands, 1991-93. Child Care Health Dev. Jan 2000;26(1):73-82. [Medline].

  4. Altemeir WA. What is happening to children with failure to thrive?. Pediatr Ann. Sep 2000;29(9):531, 534. [Medline].

  5. Boddy J, Skuse D, Andrews B. The developmental sequelae of nonorganic failure to thrive. J Child Psychol Psychiatry. Nov 2000;41(8):1003-14. [Medline].

  6. Botero D, Lifshitz F. Intrauterine growth retardation and long-term effects on growth. Curr Opin Pediatr. Aug 1999;11(4):340-7. [Medline].

  7. Careaga MG, Kerner JA. A gastroenterologist's approach to failure to thrive. Pediatr Ann. Sep 2000;29(9):558-67. [Medline].

  8. Gahagan S. Failure to thrive: a consequence of undernutrition. Pediatr Rev. Jan 2006;27(1):e1-11. [Medline].

  9. Schwartz ID. Failure to thrive: an old nemesis in the new millennium. Pediatr Rev. Aug 2000;21(8):257-64; quiz 264. [Medline].

  10. Sidebotham P. Failure to thrive. Arch Dis Child. May 2000;82(5):428. [Medline].

  11. Smith Z. Failure to thrive: early intervention to address dietary issues is vital. Community Nurse. Oct 1999;5(9):S3-4, S6. [Medline].

  12. Wright CM. Identification and management of failure to thrive: a community perspective. Arch Dis Child. Jan 2000;82(1):5-9. [Medline].

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Further Reading

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Keywords

failure to thrive, child abuse, child neglect, FTT, organic failure to thrive, nonorganic failure to thrive, pediatric growth failure, maternal or parental deprivation syndrome, nutrition, neglect, malnutrition, cigarette use, sepsis, jaundice, feeding intolerance, phenylketonuria, inborn errors of metabolism, diarrhea, dysphagia, substance abuse, cachexia, marasmus, Down syndrome, achondroplasia, Turner syndrome, ptosis, sunset sign, palpebral fissures, toxoplasmosis, rubella, cytomegalovirus infection, herpes simplex, TORCH, cataracts, palate deformity, submucous cleft, glossitis, thrush, organomegaly

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Contributor Information and Disclosures

Author

Andrew P Sirotnak, MD, Department Head, Child Abuse and Neglect, Director, Kempe Child Protection Team
Andrew P Sirotnak, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Coauthor(s)

Antonia Chiesa, MD, Senior Instructor of Pediatrics, University of Colorado at Denver Health Sciences Center
Antonia Chiesa, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Carol Diane Berkowitz, MD, Executive Vice Chair, Department of Pediatrics, Professor, Harbor-University of California at Los Angeles Medical Center
Carol Diane Berkowitz, MD is a member of the following medical societies: Alpha Omega Alpha, Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, American Medical Association, American Pediatric Society, and North American Society for Pediatric and Adolescent Gynecology
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Division Chair of Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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