Approach Considerations
The primary determination is to recognize and adequately address the secondary contributors to growth impairment even after appropriate categorization into the three main etiologies: inadequate intake, increased metabolic demand, or inefficient utilization of adequate intake.
Approach each child as being on a spectrum in which pure organic and non-organic failure are at the extremes and most have multiple reasons for their inadequate intake.
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.
Refeeding syndrome is a potential short-term complication during inpatient treatment. However, in a retrospective US study of 179 children aged 3 years and younger who had been hospitalized for failure to thrive, no evidence of refeeding syndrome was found on routine laboratory monitoring of electrolyte levels. [65]
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. [66] 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.
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.
There is also some data that suggest that complicated NICU stays can be associated with long standing feeding aversion related to the stressors of early life. [67]
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.
Clinical interventions for FTT
Feeding therapy
The child with failure to thrive who presents with what appears to be either a defined illness or as a non organic FTT, often has feeding and swallowing deficits. Speech-language pathologists have been involved in the assessment of and management of pediatric feeding and swallowing disorders since the 1930s. These individuals are commonly speech therapists who have received additional training in the physiology of the oropharyngeal phase of swallowing. Their roles in treating feeding and swallowing disorders include the following.
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Feeding and swallowing evaluations consider the child’s medical and/or neurological problems, functional ability to eat safely, oral motor development, ability to maintain nutrition and hydration. [68]
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The detailed history, includes a description and observation of how the child handles foods of different consistencies.
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Assessment is made of structural abnormalities, problems related to increased or decreased body tone, oral-motor feeding skills, and oral pharyngeal phases of the swallow.
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Diagnostic testing delineates the structures and dynamic functions of suckling, swallowing and chewing and cardiopulmonary correlates, eg, modified barium swallow study, barium swallow, and less often fiberoptic nasopharyngolaryngoscopy endoscopic assessment. [69]
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Also known as a cinefluoroscopy or videofluoroscopy, the modified barium swallow (MBS) documents the swallowing process and then is reviewed in slow motion to detect traces of penetration and aspiration.
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While a key determinant is whether the main problem is oral, pharyngeal, or esophageal, the inter-relationship between these disorders often makes this difficult. Thus, the MBS should routinely include both the pharyngeal phase and at least a screening of the esophagus. Very often it may be a disorder of both or an esophageal disorder which appears as a pharyngeal symptom.
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Even in the face of identified and treated pathologic conditions, the child may continue to have FTT related to a significant behavioral component. Many of these children have developed a conditioned aversion to eating which persists even after effective therapy has been instituted.
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FTT that began as a result of anatomical anomalies may also persist even after technically sound surgical repair. Interruption in the critical periods for introduction of food consistencies and delays in the development of feeding skills need to be recognized and addressed.
Behavioral interventions
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.
The scope includes educating and training the parent/care provider to implement improved feeding and swallowing programs .This includes the foods to work on, ways to enhance calories, feeding schedules, textures, amounts and modifying approaches as progress is made.
Children with FTT may demonstrate a variety of behaviors to avoid eating including crying, tantrums, throwing food, excessive talking, vomiting, and expelling food. Parents respond to these behaviors by coaxing, pleading, yelling, and threatening, which provide attention to the child’s refusal behavior.
In a review of 38 treatment intervention studies of subjects with medical conditions, the primary focus was to describe the behavioral components of the intervention. In 21 of the 38 intervention studies ignoring was paired with providing attention contingent on appropriate mealtime behaviors like eating. Positive reinforcement was the most common component described. Positive reinforcement helped teach the children that eating was no longer associated with discomfort and instead became an enjoyable activity. [70]
A variety of behavioral therapy methods have been successfully employed to treat feeding refusal. [71, 72, 73, 74, 75]
A significant addition to treat the difficult FTT child has been the development of comprehensive behavioral treatment programs. These can be at inpatient, or outpatient centers or through home based therapy programs. The goal includes teaching parents and caregivers how to continue the intervention and ultimately change the child’s behavior. The parents are often directed to provide a good proportion of this therapy with additional home visits by the therapist.
The time it takes to successfully implement behavioral treatment programs varies with the severity of the child’s condition and the intensity of the treatment program. Some children can be treated on an outpatient basis in their home by a specially trained speech pathologist with daily follow through by the parent or caregivers. Other children require more intensive treatment interventions that are possible only with daily outpatient or inpatient intervention for many weeks. For extreme cases, hospital-based outpatient and inpatient feeding programs have been successful
A study looking at weight recovery of children in an interdisciplinary specialty practice found that the greatest weight recovery over a 6 month period in younger children and in children who had multiple risk child related and/ or household risk factors. [76] The greater recovery in younger children emphasizes the importance of implementing these interventions early before habit formations.
Rarely, the practitioner encounters a child with nonorganic failure to thrive secondary to a disordered family unit that appears resistant to remedial therapy. A comprehensive review provides an invaluable resource for caregivers, “Hope for Children and Families”. [77] 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.
For patient education resources, see the Growth Hormone Deficiency Center, as well as Growth Failure in Children.
Diet
The long-term goal for every child with failure to thrive is to provide adequate energy intake for growth. [78] 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 CO2 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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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) |
