Failure to Thrive Treatment & Management

Observation of feeding is very important. Pay careful attention to the following:

• Maternal (caregiver) attachment during the feeding process;^[6] evaluation of signs of maternal attachment (eye contact, vocalizations, interpretation of cues)
• Evaluation of the child-parent dyad (eg, conflict over eating related to poor limit setting, lack of discipline, or meal time disruption)
• The perception of parents and/or caregivers regarding the problem
• Feeding techniques (forced feeding)

A 72-hour diet diary that includes the following can be helpful:

• Details relative to growth from breastfeeding or bottle-feeding
• Formula preparation and amounts provided
• Time and amount of feedings (eg, 5 oz of Enfamil; one-half jar of strained peaches)
• Behaviors of infant or child during feeding or nursing

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. Other dietary instructions should include the following:

• Eliminate empty calories from items such as soda or other high sugar drinks.
• Schedule regular meals and snacks (usually 3 meals and 2 snacks per day). No grazing between meals.
• Offer solids before liquids.
• Consider fortifying calories with extra oils and carbohydrates.
• Increase protein.
• Consider vitamin and/or mineral supplements, especially zinc and iron.

Provide support for the caregiver and offer suggestions for improving the feeding environment, such as the following:

• Avoid blaming the caregiver.
• Provide respite for the caregiver.
• Avoid distractions, such as television, at meal time.
• Offer a role model for the caregivers.

Psychosocial evaluation must be detailed and must provide an in-depth look at the functioning of the family and the child in the context of the family. Many impoverished and/or uneducated parents have children with growth failure; however, many have children with normal growth. The background of the parents and their attitudes and beliefs about child rearing may affect how their children are fed and how they grow. An appropriate beginning for this inquiry is to ask family members about their perception of the child's growth failure and medical condition. Inquire about the caregivers' level of concern and note whether it is discordant with the clinician's level of concern. Often, a disturbance in bonding may be obvious, but signs of problems with attachment can also be subtle. Note whether caregivers are changed or substituted frequently at feeding times. Current and past social history of the family, at a minimum, should address the following:

• Finances and resources, living and childcare arrangements
• Abuse and neglect risk factors, including any physical or sexual abuse
• Domestic or interpersonal violence
• Substance abuse or addiction
• Mental health disorder, particularly depression and postpartum depression
• Eating disorder

Surgical care is most often not needed unless an underlying condition, such as cleft palate, must be repaired. Gastrostomy feeding tube placement may be needed in severe cases of malnutrition, especially in children with neurodevelopmental delay.

An interdisciplinary approach is vital in the assessment and care of infants and children with failure to thrive (FTT) and growth failure, especially when the cause is predominantly psychosocial. Even in cases where organic or medical causes are predominant, a coordinated team approach helps the family understand the diagnosis and care plan.

• Consult a nutritionist early for evaluation of caloric needs, for anthropometric measurements, and for assistance with a dietary plan of care.
• Involve developmental specialists early on to provide baseline assessment, monitor growth, and monitor for any delays and improvements over time.
• Consulting a physical or occupational therapist may be necessary for patients with motor delays and weakness. A pediatric therapist who can assist with treatment plans can assess oromotor feeding skills. Most pediatric care facilities have oromotor skill therapists who provide this evaluation.
• Mental health professionals, including social workers, behavioral-developmental pediatricians, psychiatric nurses and nurse practitioners, psychologists, and psychiatrists, are crucial in the evaluation of the family and child. They are also necessary to provide support for the caregiver and child.

  • Parent education secondary to parenting skill assessment can offer valuable help and may be provided as well.
  • In-home assessment is important to evaluate the environment, resources, and feeding interactions in the usual setting.
• An infant with growth failure from a dysfunctional care setting or family environment may thrive when placed in a more functional caring home. Reporting to county social services (child protection services) may be indicated with the following:

  • If risk, suspicion, or documented abuse or neglect is observed
  • If situations or factors are present that cannot be addressed by the care team alone (eg, homelessness, substance abuse, violence, family uncooperative with the care plan) because the infant or child can be considered a victim of medical care neglect
  • If the family needs monitoring and support to assure compliance

Diet is outlined above. Diet must be individualized according to the age and nutritional status of the child or infant. Simply increasing the patient's energy intake may not cause growth to occur if the underlying comorbid psychosocial pathology is not addressed as well.

Activity may be adjusted with physical therapy if needed.