Nutritional Considerations in Failure to Thrive Treatment & Management

Most children with failure to thrive (FTT) can be treated as outpatients. However, serial visits are mandatory, with documentation of weight gain and/or daily caloric intake. Home visits can help determine the underlying reason for the nonorganic failure to thrive and can help support the caregiver. If outpatient trials do not lead to documented weight gain, then hospitalization is necessary for diagnostic and therapeutic reasons. Diagnostic benefits of admission may include observation of feeding, parental-child interaction, and dietary habits. Additionally, specific tests can be performed and subspecialists can be consulted in this setting.

If no weight gain is documented after several days of allowing the caregiver to feed the child with close observation in a structured setting, then experienced hospital personnel must take over feeding. Failure to gain weight under these circumstances strongly suggests that an organic etiology is making a major contribution or that a complex behavioral issue is present. Conversely, if weight gain is documented by other caregivers, then improving the behavioral dynamics of the child and parent becomes the focus.

Therapeutic benefits should be anticipated from hospitalization. Acute needs, such as dehydration, infection, anemia, or electrolyte imbalance, can be addressed and managed with intravenous fluids, systemic antibiotic therapy, and transfusion. If no weight gain is documented by alternative caregivers, then a trial of nasogastric tube feeding should be implemented to see if the child can absorb enough energy if adequate amounts are provided to grow. If not, administration of simplified nutritional products or even parenteral nutrition can be initiated while a comprehensive understanding of the deficits are sought. Once the organic etiology is found, specific therapy should be immediately initiated during the hospitalization.

Another benefit of hospitalization is the opportunity for observing the parent-child interaction. In addition to the feeding techniques of the parents, other interactions can be observed more easily in the hospital. Multiple observers should assess and document the degrees to which parents bond, speak, and even interact with their children.

Children born with congenital anomalies of their GI tract require surgical corrective procedures to provide for a continuous patent system to digest and absorb nutrition. Unfortunately, the surgically corrected system is often problematic and can interfere with adequate growth. An experienced pediatric surgeon should be actively involved in the care of a child with failure to thrive who has previously had GI tract surgery.

When treating children with failure to thrive, an interdisciplinary team approach combining pediatric, nutritional, mental health, and social work is optimal. An interdisciplinary approach ensures that programs such as women, infants, and children (WIC); food stamps; and Medicaid can be accessed. The team should also coordinate home-based services and follow up after discharge.

An interdisciplinary team should evaluate the family's psychosocial situation and determine if future support is required. An older child with a chronic illness and failure to thrive may benefit from referral to a psychologist. If neglect is suspected, child protective services should become involved. Pediatric medical or surgical subspecialists should be involved in the long-term treatment and monitoring of organic illness if identified.

The most significant addition to the failure to thrive team is pediatric feeding therapists. These individuals are commonly speech therapists who have received additional training in the physiology of the oropharyngeal phase of swallowing. Usually, an initial assessment is performed after taking a detailed history, including a description of how the child handles foods of different consistencies. Preliminary determination is made whether the problem is oral, pharyngeal, or esophageal. The child is observed after being fed food of various consistencies. If appropriate, a modified barium swallow is performed as described above.

Once problems are identified, specific therapeutic regimens can be instituted, including the need for behavioral feeding programs. Like all other forms of physical and or occupational therapy, a prolonged regimen of training the family and implementing the program is often required to correct deficits. Thus, parents are often directed to provide a good proportion of this therapy with additional home visits by the therapist. For extreme cases, hospital-based outpatient and inpatient feeding programs have been successful.

The long-term goal for every child with failure to thrive is to provide adequate energy intake for growth.^[29] For a child with organic failure to thrive, aggressive dietary management is the cornerstone of therapy. Additional caloric intake can be achieved with formulas that provide 120 kcal/kg of ideal body weight per day for infants who cannot ingest the required volume of standard formula. Usually, the density is increased from 20 to 24-27 kcal/oz. Some clinicians prefer to achieve the same result by adding lipids, carbohydrates, combinations of both, and (rarely) protein to standard 20 kcal/oz formulas.

Infants given concentrated formulas must have normal renal function because the osmolar load is proportionally higher as well. Infants and children with cardiopulmonary disease may require additional energy to compensate for the additional work of breathing so rapidly. They will benefit from lipid supplementation because fat is burned with a lower respiratory coefficient, yielding less CO ₂ to expire than carbohydrate or protein.

Supplementation for older children may include adding meat sauces, oil, cheese, sour cream, butter, margarine, or peanut butter to meals. Also, high-energy (approximately 1 kcal/mL) shakes, which are available in different flavors, provide a good supplement (eg, Pedia Sure, Kindercal, Boost). Multivitamin and mineral supplements, including iron and zinc, are usually recommended to all undernourished children.

Temporary tube feeding is rarely indicated, except for in children with severe malnutrition and debilitation. In infants or children with organic failure to thrive that is secondary to high energy demands or significant dysphagia, long-term continuous nighttime tube feeding may be required to sustain growth.

Table 2. Examples of High-Calorie Fortifiers (Open Table in a new window)

Table 3. Examples of High-Calorie Nutritional Products (Open Table in a new window)

Many generic products offer a substantially less expensive, nutritionally adequate alternative.