Nutritional Considerations in Failure to Thrive Treatment & Management

  • Author: Simon S Rabinowitz, MD, PhD, FAAP; Chief Editor: Jatinder Bhatia, MBBS, FAAP  more...
 
Updated: Apr 24, 2014
 

Medical Care

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.

A provocative report analyzed hospitalization for failure to thrive and found that there was an increased length of stay (and cost) associated with weekend admission.[37] While the data presented represent their experience, it is important for practitioners to be aware of this phenomenon and create explicit data collection goals for the weekend inpatient team. This increases the likelihood that valuable information is collected. For situations that do require hospitalization of children of working parents, often with additional school-aged children, a 10-day admission that includes 2 weekends would minimize interruption of school and work and, therefore, be optimal.

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Surgical Care

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.

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Consultations

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.

Rarely, the practitioner encounters a child with nonorganic failure to thrive secondary to a disordered family unit that appears resistant to remedial therapy. A recent comprehensive review provides an invaluable resource for caregivers, “Hope for children and families”.[38] The manual represents an analysis of 22 randomized controlled trials on situations in which children are subjected to harmful or neglectful parenting. The recommendations include providing individual therapy for the parent, promoting family engagement, positive reinforcement for the parent, and teaching both coping and nutritional skills.

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Diet

The long-term goal for every child with failure to thrive is to provide adequate energy intake for growth.[39] 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)

Product Calories Source
Medium-chain triglyceride (MCT) oil 7.7 kcal/mL Fractionated coconut oil
Microlipid 4.5 kcal/mL Safflower oil
Corn oil 8.4 kcal/mL Corn
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/tbsp Rice flour
Nonfat dry milk powder 15 kcal/T (1.5 g protein) Cow's milk
Powder infant formula 40 kcal/tbsp Cow's milk
Liquid concentrated infant formula 40 kcal/oz Cow's milk

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

Product, 30 kcal/oz CHO, g/100 mL Protein, g/100 mL Fat, g/100 mL Osmolality Nutrient Sources
Nutren Junior



(Clintec)



12.8 3 4.2 350 CHO - Maltodextrin, sucrose



Protein - Casein, whey



Fat - Soy, MCT, and canola oils



(Vanilla, also available with fiber)



Kindercal



(Mead Johnson)



13.5 3.4 4.4 310 CHO - 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)



11 3 5 310 CHO - 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)



17.4 4.3 1.7 590-620 CHO - Sucrose, corn syrup solids



Protein - Milk protein concentrate



Fat - Canola, sunflower, corn oils



(Chocolate, chocolate mocha, strawberry, vanilla)



 

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

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Contributor Information and Disclosures
Author

Simon S Rabinowitz, MD, PhD, FAAP Professor of Clinical Pediatrics, Vice Chairman, Clinical Practice Development, Pediatric Gastroenterology, Hepatology, and Nutrition, State University of New York Downstate College of Medicine, The Children's Hospital at Downstate

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

Disclosure: Nothing to disclose.

Coauthor(s)

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.

Navneetha Unnikrishnan, MBBS Resident Physician, Department of Pediatrics, State University of New York Downstate College of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Jatinder Bhatia, MBBS, FAAP Professor of Pediatrics, Medical College of Georgia, Georgia Regents University; Chief, Division of Neonatology, Director, Fellowship Program in Neonatal-Perinatal Medicine, Director, Transport/ECMO/Nutrition, Vice Chair, Clinical Research, Department of Pediatrics, Children's Hospital of Georgia

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

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Gerber.

Chief Editor

Jatinder Bhatia, MBBS, FAAP Professor of Pediatrics, Medical College of Georgia, Georgia Regents University; Chief, Division of Neonatology, Director, Fellowship Program in Neonatal-Perinatal Medicine, Director, Transport/ECMO/Nutrition, Vice Chair, Clinical Research, Department of Pediatrics, Children's Hospital of Georgia

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

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Gerber.

Additional Contributors

Maria Rebello Mascarenhas, MBBS Associate Professor of Pediatrics, University of Pennsylvania School of Medicine; Section Chief of 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, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Acknowledgements

Rita Alvarez, MD Resident Physician, Department of Pediatrics, State University of New York Downstate Medical Center, Brooklyn

Rita Alvarez, MD is a member of the following medical societies: American Medical Student Association/Foundation

Disclosure: Nothing to disclose.

Reda W Bassali, MBChB Associate Professor, Departments of General Pediatrics and Adolescent Medicine, Medical College of Georgia

Reda W Bassali is a member of the following medical societies: Ambulatory Pediatric Association and American Academy of Pediatrics

Disclosure: Nothing to disclose.

John Benjamin, MD Chief, General Section of Pediatrics and Adolescent Medicine, Vice Chair for Clinical Activities, Professor, Department of General Pediatrics, Medical College of Georgia

Disclosure: Nothing to disclose.

Mohammad F El-Baba, MD Associate Professor of Pediatrics, Division of Pediatric Gastroenterology, Wayne State University School of Medicine; Divison Chief of Pediatric Gastroenterology, Children's Hospital of Michigan

Mohammad F El-Baba, MD is a member of the following medical societies: American Gastroenterological Assocation and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

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.

Ruby Mehta, MD Fellow, Division of Pediatric Gastroenterology, Children's Hospital of Michigan

Disclosure: Nothing to disclose.

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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 causes Inadequate 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
Product Calories Source
Medium-chain triglyceride (MCT) oil 7.7 kcal/mL Fractionated coconut oil
Microlipid 4.5 kcal/mL Safflower oil
Corn oil 8.4 kcal/mL Corn
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/tbsp Rice flour
Nonfat dry milk powder 15 kcal/T (1.5 g protein) Cow's milk
Powder infant formula 40 kcal/tbsp Cow's milk
Liquid concentrated infant formula 40 kcal/oz Cow's milk
Table 3. Examples of High-Calorie Nutritional Products
Product, 30 kcal/oz CHO, g/100 mL Protein, g/100 mL Fat, g/100 mL Osmolality Nutrient Sources
Nutren Junior



(Clintec)



12.8 3 4.2 350 CHO - Maltodextrin, sucrose



Protein - Casein, whey



Fat - Soy, MCT, and canola oils



(Vanilla, also available with fiber)



Kindercal



(Mead Johnson)



13.5 3.4 4.4 310 CHO - 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)



11 3 5 310 CHO - 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)



17.4 4.3 1.7 590-620 CHO - Sucrose, corn syrup solids



Protein - Milk protein concentrate



Fat - Canola, sunflower, corn oils



(Chocolate, chocolate mocha, strawberry, vanilla)



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