Nutritional Considerations in Failure to Thrive Follow-up

  • Author: Simon S Rabinowitz, MD, PhD; Chief Editor: Jatinder Bhatia, MBBS   more...
 
Updated: May 4, 2010
 

Further Outpatient Care

Children with failure to thrive (FTT) need continued follow-up care to observe their growth parameters using the appropriate growth charts.

A randomized controlled trial of multidisciplinary home visits among children with failure to thrive found mild improvement in some parameters compared with children with failure to thrive who only attended the same clinic. However, children without failure to thrive from the same neighborhoods were significantly taller, heavier, and had better arithmetic scores at age 8 years than children with failure to thrive with or without home visits.[30] An older randomized controlled trial of specialist health visitor interventions failed to show any improvements in weight or developmental scores but did find that visited patients were more compliant with appointments and less likely to be admitted to a hospital.[31]

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Complications

Aside from the unfortunate children who live so far from the protective mechanisms of the developed world, psychosocial failure to thrive is almost always recognized early enough to be completely reversed. In the developing world, or regions of the developed countries with extreme poverty and isolation, chronic unaddressed malnutrition results in permanent deficits in stature and intelligence quotient (IQ), even when weight losses can be restored. Similarly, for the child with devastating or inadequately treated organic illnesses, long-term failure to thrive can compromise final height. Malnutrition, if dramatic enough, can contribute to secondary immune deficiency and intercurrent illnesses.

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Prognosis

Multiple studies have found that failure to thrive is associated with long-term cognitive deficits, as well as anthropometric compromise.[7, 32, 33] However, 2 meta-analyses of published studies of children with failure to thrive in developing countries found small differences in IQ scores.[7, 33] Interestingly, one group concluded that this disparity was not enough to warrant an aggressive approach to identification and treatment of this entity.[7] The other authors suggested substantial population-based cognitive deficiencies could be attributed to failure to thrive.[33]

Another longitudinal population study of a large cohort found the same degree of IQ score difference when they examined a cohort with infantile failure to thrive.[34] A separate study that further divided nonorganic failure to thrive into those who had or had not experienced neglect defined a particularly vulnerable cohort; failure to account for this additional variable may explain some differences.[35]

Although the goal of all pediatricians caring for children with organic failure to thrive is to incorporate measures into their management that are designed to preserve adequate growth, this may prove to be difficult. A greater appreciation for the significant prevalence of failure to thrive in children with cerebral palsy (CP), congenital heart disease, cystic fibrosis, cirrhosis, HIV, inflammatory bowel disease, malignancy, and genetic diseases has been noted.

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Patient Education

For excellent patient education resources, visit eMedicine's Marasmus, and Growth Hormone Deficiency Center. Also, see eMedicine's patient education articles Protein losing Enteropathy, and Growth Failure in Children,

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Contributor Information and Disclosures
Author

Simon S Rabinowitz, MD, PhD  Professor of Clinical Pediatrics, New York Medical College; Chairman, Chief and Medical Administrator, Department of Pediatrics, Chief, Pediatric Gastroenterology and Nutrition, Richmond University Medical Center

Simon S Rabinowitz, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American College of Gastroenterology, American Gastroenterological Association, American Medical Association, New York Academy of Sciences, North American Society for Pediatric Gastroenterology and Nutrition, Phi Beta Kappa, and Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

Madhavi Katturupalli, MD  Resident Physician, Department of Pediatrics, New York Medical College, Richmond University Medical Center

Madhavi Katturupalli, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Genie Rogers, MA, CCC-SLP, BRS-S  Speech-Language Pathologist, Infant and Child Learning Center, Neonatal Intensive Care Unit, Downstate University Hospital; Clinical Supervisor, Speech Therapy Services, Step by Step Infant Development Program

Genie Rogers, MA, CCC-SLP, BRS-S is a member of the following medical societies: American Speech-Language-Hearing Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Maria Rebello Mascarenhas, MBBS  Associate Professor of Pediatrics, University of Pennsylvania School of Medicine; Section Chief Nutrition, Division of Gastroenterology and Nutrition, Director, Nutrition Support Service, Children's Hospital of Philadelphia

Maria Rebello Mascarenhas, MBBS is a member of the following medical societies: American Gastroenterological Association, American Society for Parenteral and Enteral Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Jatinder Bhatia, MBBS  Professor of Pediatrics, Chief, Section of Neonatology, Department of Pediatrics, Medical College of Georgia

Jatinder Bhatia, MBBS is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American Dietetic Association, American Pediatric Society, American Society for Clinical Nutrition, American Society for Parenteral and Enteral Nutrition, Society for Pediatric Research, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

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

Jatinder Bhatia, MBBS  Professor of Pediatrics, Chief, Section of Neonatology, Department of Pediatrics, Medical College of Georgia

Jatinder Bhatia, MBBS is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American Dietetic Association, American Pediatric Society, American Society for Clinical Nutrition, American Society for Parenteral and Enteral Nutrition, Society for Pediatric Research, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

References

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  2. Frank DA, Zeisel SH. Failure to thrive. Pediatr Clin North Am. Dec 1988;35(6):1187-206. [Medline].

  3. Porter B, Skuse D. When does slow weight gain become 'failure to thrive'?. Arch Dis Child. Jul 1991;66(7):905-6. [Medline].

  4. Zenel JA Jr. Failure to thrive: a general pediatrician's perspective. Pediatr Rev. Nov 1997;18(11):371-8. [Medline].

  5. Hoare KJ. A baby presenting with failure to thrive in primary care: a case report. Cases J. 2009;2(1):137. [Medline].

  6. Leung DH, Chung CT. Cases in pediatric gastroenterology from The Children's Hospital of Philadelphia: a 2-year-old boy with diarrhea, failure to thrive, and hepatomegaly. Medscape J Med. 2009;11(1):13. [Medline].

  7. Rudolf MC, Logan S. What is the long term outcome for children who fail to thrive? A systematic review. Arch Dis Child. Sep 2005;90(9):925-31. [Medline].

  8. Olsen EM, Petersen J, Skovgaard AM, et al. Failure to thrive: the prevalence and concurrence of anthropometric criteria in a general infant population. Arch Dis Child. Feb 2007;92(2):109-14. [Medline].

  9. Reilly SM, Skuse DH, Wolke D, Stevenson J. Oral-motor dysfunction in children who fail to thrive: organic or non-organic?. Dev Med Child Neurol. Feb 1999;41(2):115-22. [Medline].

  10. Olsen EM, Skovgaard AM. [Psychosomatic failure-to-thrive in infants and toddlers]. Ugeskr Laeger. Nov 25 2002;164(48):5631-5. [Medline].

  11. Skuse DH. Non-organic failure to thrive: a reappraisal. Arch Dis Child. Feb 1985;60(2):173-8. [Medline].

  12. Manikam R, Perman JA. Pediatric feeding disorders. J Clin Gastroenterol. Jan 2000;30(1):34-46. [Medline].

  13. [Guideline] Centers for Disease Control and Prevention. CDC Growth Charts. August 4, 2009;[Full Text].

  14. [Guideline] Cronk C, Crocker AC, Pueschel SM, et al. Growth charts for children with Down syndrome: 1 month to 18 years of age. Pediatrics. Jan 1988;81(1):102-10. [Medline].

  15. [Guideline] Lyon AJ, Preece MA, Grant DB. Growth curve for girls with Turner syndrome. Arch Dis Child. Oct 1985;60(10):932-5. [Medline].

  16. [Guideline] Horton WA, Rotter JI, Rimoin DL, Scott CI, Hall JG. Standard growth curves for achondroplasia. J Pediatr. Sep 1978;93(3):435-8. [Medline].

  17. Drewett RF, Corbett SS, Wright CM. Cognitive and educational attainments at school age of children who failed to thrive in infancy: a population-based study. J Child Psychol Psychiatry. May 1999;40(4):551-61. [Medline].

  18. Prazuck T, Tall F, Nacro B, et al. HIV infection and severe malnutrition: a clinical and epidemiological study in Burkina Faso. AIDS. Jan 1993;7(1):103-8. [Medline].

  19. Lechner-Gruskay D, Honig PJ, Pereira G, McKinney S. Nutritional and metabolic profile of children with epidermolysis bullosa. Pediatr Dermatol. Feb 1988;5(1):22-7. [Medline].

  20. Berwick DM, Levy JC, Kleinerman R. Failure to thrive: diagnostic yield of hospitalisation. Arch Dis Child. May 1982;57(5):347-51. [Medline].

  21. Genero A, Moretti C, Fait P, Guariso G. [Non-organic failure to thrive: retrospective study in hospitalized children]. Pediatr Med Chir. Sep-Oct 1996;18(5):501-6. [Medline].

  22. Homer C, Ludwig S. Categorization of etiology of failure to thrive. Am J Dis Child. Sep 1981;135(9):848-51. [Medline].

  23. Daniel M, Kleis L, Cemeroglu AP. Etiology of failure to thrive in infants and toddlers referred to a pediatric endocrinology outpatient clinic. Clin Pediatr (Phila). Oct 2008;47(8):762-5. [Medline].

  24. Oates RK. Similarities and differences between nonorganic failure to thrive and deprivation dwarfism. Child Abuse Negl. 1984;8(4):439-45. [Medline].

  25. Skuse DH. Non-organic failure to thrive: a reappraisal. Arch Dis Child. Feb 1985;60(2):173-8. [Medline].

  26. Schwarz SM, Corredor J, Fisher-Medina J, Cohen J, Rabinowitz S. Diagnosis and treatment of feeding disorders in children with developmental disabilities. Pediatrics. Sep 2001;108(3):671-6. [Medline].

  27. Tannenbaum GS, Ramsay M, Martel C, Samia M, Zygmuntowicz C, Porporino M. Elevated circulating acylated and total ghrelin concentrations along with reduced appetite scores in infants with failure to thrive. Pediatr Res. May 2009;65(5):569-73. [Medline].

  28. Sills RH. Failure to thrive. The role of clinical and laboratory evaluation. Am J Dis Child. Oct 1978;132(10):967-9. [Medline].

  29. Maggioni A, Lifshitz F. Nutritional management of failure to thrive. Pediatr Clin North Am. Aug 1995;42(4):791-810. [Medline].

  30. Black MM, Dubowitz H, Krishnakumar A, Starr RH Jr. Early intervention and recovery among children with failure to thrive: follow-up at age 8. Pediatrics. Jul 2007;120(1):59-69. [Medline].

  31. Black MM, Dubowitz H, Hutcheson J, Berenson-Howard J, Starr RH Jr. A randomized clinical trial of home intervention for children with failure to thrive. Pediatrics. Jun 1995;95(6):807-14. [Medline].

  32. Reif S, Beler B, Villa Y, Spirer Z. Long-term follow-up and outcome of infants with non-organic failure to thrive. Isr J Med Sci. Aug 1995;31(8):483-9. [Medline].

  33. Corbett SS, Drewett RF. To what extent is failure to thrive in infancy associated with poorer cognitive development? A review and meta-analysis. J Child Psychol Psychiatry. Mar 2004;45(3):641-54. [Medline].

  34. Emond AM, Blair PS, Emmett PM, Drewett RF. Weight faltering in infancy and IQ levels at 8 years in the Avon Longitudinal Study of Parents and Children. Pediatrics. Oct 2007;120(4):e1051-8. [Medline].

  35. Mackner LM, Starr RH Jr, Black MM. The cumulative effect of neglect and failure to thrive on cognitive functioning. Child Abuse Negl. Jul 1997;21(7):691-700. [Medline].

 
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Failure of growth in weight, length, and head circumference starting at birth, suggesting an organic etiology that occurred in utero.
Growth failure in length and weight with a normal head circumference in an infant with growth hormone deficiency.
Acquired hypothyroidism.
Constitutional delay of growth.
Failure to thrive secondary to caloric deprivation.
Table 1. Summary of Organic Causes of Failure to Thrive
Prenatal causes
  • Prematurity with complications
  • Maternal malnutrition
  • Toxic exposure in utero
  • Alcohol, smoking, medications, infections
  • IUGR
  • Chromosomal abnormalities
Postnatal causesInadequate intake



  • Lack of appetite (chronic illness)
  • Inability to suck or swallow
  • Vomiting
  • Therapy used to treat primary illness (eg, chemotherapy)
  • Developmental delay
  • GI pain or dysmotility
Poor absorption and/or use of nutrients



  • Malabsorption
  • Anatomical GI problems
  • Pancreatic and cholestatic conditions
  • Inborn errors of metabolism
  • Chronic GI infections
Increased metabolic demand



  • HIV infection
  • Malignancy
  • Cardiopulmonary diseases and inflammatory conditions
  • Renal failure
  • Hyperthyroidism
Table 2. Examples of High-Calorie Fortifiers
ProductCaloriesSource
Medium-chain triglyceride (MCT) oil7.7 kcal/mLFractionated coconut oil
Microlipid4.5 kcal/mLSafflower oil
Corn oil8.4 kcal/mLCorn
ProMod (protein powder)28 kcal/scoop (4.2 kcal/g)



5 g/scoop



Whey protein with lecithin
Polycose (powder or liquid)Powder - 23 kcal/tbsp



Liquid - 30 kcal/tbsp



Powder - Hydrolyzed cornstarch



Liquid - Glucose polymers derived from hydrolyzed cornstarch



Rice cereal (powder)15 kcal/tbspRice flour
Nonfat dry milk powder15 kcal/T (1.5 g protein)Cow's milk
Powder infant formula40 kcal/tbspCow's milk
Liquid concentrated infant formula40 kcal/ozCow's milk
Table 3. Examples of High-Calorie Nutritional Products
Product, 30 kcal/ozCHO, g/100 mLProtein, g/100 mLFat, g/100 mLOsmolalityNutrient Sources
Nutren Junior



(Clintec)



12.834.2350CHO - Maltodextrin, sucrose



Protein - Casein, whey



Fat - Soy, MCT, and canola oils



(Vanilla, also available with fiber)



Kindercal



(Mead Johnson)



13.53.44.4310CHO - Maltodextrin, sucrose



Protein - Caseinates, milk protein concentrate



Fat - Canola, MCT, and high-oleic sunflower oils



Contains soy fiber 6.3 g/L



(Vanilla)



PediaSure



(Ross)



1135310CHO - Corn syrup solids, sucrose



Protein - Caseinate, whey protein concentrate



Fat - High-oleic safflower, soy, and MCT oils



(Vanilla, also available with fiber)



Boost



(Mead Johnson)



17.44.31.7590-620CHO - Sucrose, corn syrup solids



Protein - Milk protein concentrate



Fat - Canola, sunflower, corn oils



(Chocolate, chocolate mocha, strawberry, vanilla)



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