History
The most important part of the evaluation of a child with failure to thrive (FTT) is obtaining a careful, detailed history. Once identified, the history can reveal whether the failure to thrive is organic, nonorganic (no identifiable physical conditions contributing to the problem), [58, 59, 60] or has components of both. As suggested above, the keen clinician will strive to identify subtle organic problems that may influence eating in seemingly healthy but deprived children as well as psychosocial challenges that further compromise intake in sick children. [21, 16]
The next step is to establish whether the parent of a child with organic failure to thrive feels that it is related to decreased intake, increased losses (eg, diarrhea, emesis) or abnormal metabolism (chronic illnesses, especially cardiopulmonary illnesses that increase the basal metabolic rate). Often times, multiple factors can coalesce in a single patient.
The history should include the following:
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Prenatal/perinatal history: This should include history, information regarding smoking, alcohol use, use of medications, illnesses (including rashes), gestational age, single or multiple births, parturition events and any data on prenatal growth.
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A review of the events in the nursery: This should include feeding problems and medical conditions, especially those that delay discharge. Mothers of infants in the neonatal intensive care unit (NICU) or discharge summaries should be queried for oropharyngeal or gastrointestinal setbacks, as well as a timeline for the introduction of tube feeds, and the transition to oral feeds.
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Detailed feeding history (with a documentation of how many ounces or liters are consumed in a 24-hour period rather than 3 oz every 3 h): Breastfed babies should have 7 or more wet diapers per day and regular passage of stools.
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Inquire as to when the rate of weight gain first become a concern. Was it present when being breast or formula fed or was it associated with the transition to solid food or afterwards?
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Description of how the mother prepares any formula which is not ready to feed: Improperly prepared formula can result in failure to thrive and serious electrolyte imbalances. The use of any supplements to formulas and/or substitutes for formulas should be identified.
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Description of the type of solid foods eaten (including the quantitative composition and frequency of meals and snacks): If a detailed history is difficult to obtain, parents should bring in a 3-day food diary, as well as the jars and/or labels from foods that the child is eating or if available photos on their cell phones. For infants and toddlers, include the amount of formula/milk or milk substitute the child is taking. Nutritionists are helpful in interviewing parents and calculating the exact number of calories consumed.
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Previously charted growth: Previous documentation of anthropometric data from the primary physician, health station, clinic, or electronic medical records should be referred to when analyzing the data. If any changes in rate of weight gain are noted, the primary care taker should be asked about changes in feeding and additional changes, including introduction of new foods, change from breast milk to formula or between formulas, and changes in the primary individuals responsible for feeding the child. Finally, any changes in family dynamics should be investigated. Multiple modulations is a defined risk factor that may go unnoticed. [17]
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Details about any illnesses that occurred since the neonatal period (particularly those that require hospitalization or are chronic and/or permanent) including weight changes during these events as well as weights at admission and discharge.
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Medical problems that can compromise eating (eg, cleft palate, cerebral palsy, spasticity, seizures, delayed development, and low motor tone) require closer scrutiny regarding caloric intake.
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Family and social history: This should include growth and eating pattern of other siblings, living conditions, stressors, and data on parents' growth history.
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A drug history should be part of evaluating any adolescents who present with failure to thrive. A retrospective review of adolescent inhalant abuse found that the growth impairment in some of these individuals met the failure to thrive criteria. [61]
Physical Examination
Growth charts
The first thing that pediatricians should do in all health assessments is to plot the head circumference, height, and weight on a growth chart. Previous growth parameters should be used to detect trends in growth rather than relying on measurements at one particular visit. If weight, height, and head circumference are all compromised, this suggests an in utero insult and/or genetic or chromosomal abnormality (see the image below).
Failure of growth in weight, length, and head circumference starting at birth, suggesting an organic etiology that occurred in utero.
If weight and height growth are delayed with a normal head circumference, endocrinopathies (see the first 2 images below) or constitutional delay (see the third image below) should be suspected.
Growth failure in length and weight with a normal head circumference in an infant with growth hormone deficiency.
This pattern also can occur in long-standing failure to thrive. Ultimately, head circumference is delayed, emphasizing the importance of following these growth parameters over time. When only weight gain is delayed, this usually reflects recent energy (caloric) deprivation (see the image below).
Vital signs are usually within the reference range, but blood pressure, respiration rate, pulse rate, and oxygen saturation may provide important clues regarding the etiology.
Abnormalities in children with organic basis for failure to thrive
The physical examination may reveal the following abnormalities in children with organic basis for failure to thrive:
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Edema including ascites - Renal disease, liver disease, protein-losing enteropathy
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Wasting - Cancer, HIV, CP, poorly controlled inflammatory disease
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Hepatomegaly - Liver infiltration by tumor, storage disease, or cirrhosis
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Heart murmur, hepatosplenomegaly - Congenital heart disease
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Hepatosplenomegaly - Infiltrative diseases, malignancy
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Respiratory compromise -Cystic fibrosis, bronchopulmonary dysplasia
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Rash or skin changes - HIV, congenital syphilis, cow's milk protein allergy, lupus
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Hair color and texture changes - Zinc deficiency, Menkes kinky hair disease
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Mental status changes - CP
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Signs of vitamin deficiency -Celiac disease, parasites, other enteropathy
Decreased weight secondary to marasmus (caused by insufficient caloric intake) should be distinguished from decreased weight secondary to acute dehydration. Only the latter is characterized by decreased skin turgor, sunken anterior fontanelle, dry mucous membranes, absence of tears, and acutely ill appearance.
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Failure of growth in weight, length, and head circumference starting at birth, suggesting an organic etiology that occurred in utero.
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Growth failure in length and weight with a normal head circumference in an infant with growth hormone deficiency.
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Acquired hypothyroidism.
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Constitutional delay of growth.
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Failure to thrive secondary to caloric deprivation.
Tables
Prenatal causes |
|
Postnatal causes |
Inadequate intake
Poor absorption and/or use of nutrients
Increased metabolic demand
|
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 |
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) |
