Nutritional Considerations in Failure to Thrive Follow-up

Updated: Dec 02, 2016
  • Author: Simon S Rabinowitz, MD, PhD, FAAP; Chief Editor: Jatinder Bhatia, MBBS, FAAP  more...
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Follow-up

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. [78] 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. [79]

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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 investigated whether failure to thrive is associated with long-term cognitive deficits. [33, 37, 38] Two published meta-analyses looking at cognitive outcomes of published children with failure to thrive in developed countries found small differences consisting of 3-4 IQ points. [33, 38] Interestingly, one group concluded that this disparity was not enough to warrant an aggressive approach to identification and treatment of this entity. [33] The other authors suggested substantial population-based cognitive deficiencies could be attributed to failure to thrive. [38]

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. [39] 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. [40]

A new area of research has been exploring whether aggressive refeeding or early malnutrition itself could impact future health parameters independent of simply changes in BMI and growth. The Barker or Fetal Origins Hypothesis is based on data accumulated over the last 20 years that has linked low birth weight to a subsequent increased risk for cardiovascular disease and type 2 diabetes. This theory states that in utero nutrient restriction results in epigenetic modifications that reprogram intermediary metabolism, glucose regulation, and blood pressure regulation. These genetic changes persist into adult life and yield increased susceptibility to disease.

A few epidemiologic studies have hypothesized that this principle could be extended to include malnutrition occurring in early postnatal life. A comprehensive review summarizes the published literature in this field and concludes that children with early-onset enteric infections, malnutrition, and stunting appear to be at increased risk to ultimately develop the metabolic syndrome. [41] A small observational study describes a cohort of young children with severe failure to thrive who received aggressive nutritional rehabilitation and ultimately developed obesity. [42] Whether this was a consequence of the primary deficit or the therapy is not addressed.

Potential long-term psychosocial consequences of stunting secondary to growth failure in early childhood have been highlighted by a longitudinal study following a rural Guatemalan cohort. [43] Affected individuals went on to have profound consequences in adulthood related to economic status, marriage, and fertility. They scored worse on tests of reading and intelligence and had lower cognitive skills. Men had decreased likelihood of entry into higher-salaried positions. Individuals who were stunted often entered into relationships with poorer partners and were more likely to live in poorer households as adults. Women with stunting had their first child at a younger age and had more pregnancies and more children. While provocative, the potential for other economic, educational, or sociologic factors being the primary explanation for these outcomes still needs to be considered.

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  most chronic illnesses including 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 patient education resources, see the Growth Hormone Deficiency Center, as well as Growth Failure in Children,

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