Nutritional Considerations in Failure to Thrive Workup: Laboratory Studies, Imaging Studies, Procedures

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Nutritional Considerations in Failure to Thrive

Sections Nutritional Considerations in Failure to Thrive
Overview
Presentation
DDx
Workup
Treatment
Medication
Follow-up
Media Gallery
Tables
References

Workup

Laboratory Studies

Because many instances of failure to thrive are nonorganic, a history and physical examination are normally all that are required. Laboratory assessment has a limited value in diagnosing a previously unknown clinical disease or demonstrating inadequate treatment (ie, improper regiments or more commonly noncompliance).^{[62, 63]}

Children diagnosed with failure to thrive usually undergo certain screening tests that are more helpful in determining their physical status rather than elucidating the etiology. These often including the following:

CBC count
Urinalysis
Urine culture
Electrolytes, including creatinine and BUN
Liver function tests, including total protein and albumin
Prealbumin (may be used as a nutritional marker)

More specific tests may be indicated, depending on findings from the history and physical examination, including the following:

Erythrocyte sedimentation rate (ESR) to establish objective inflammation
HIV testing
Sweat chloride test
Thyroid function tests
Stool studies for parasites or malabsorption
Immunoglobulins and other immune studies
Purified protein derivative (PPD) skin test
Radiological studies
Tissue transglutaminase antibody (TTG-IgA), a screen for celiac disease (prevalence now appreciated to be 1 case per 133 population)

If concern surrounds possible growth hormone deficiency, the following may be obtained:

Serum insulinlike growth factor I (IGF-I)
Insulinlike growth factor binding protein (IGF-BP3)

Note that in patients with failure to thrive, the growth hormone axis may be secondarily affected, a condition referred to as deprivational dwarfism.

Imaging Studies

Bone age may be helpful in distinguishing genetic short stature from constitutional delay of growth. Chest radiography is helpful in assessing cardiopulmonary disease.

For a child with suspected dysphagia, which may present as coughing, choking, difficulty with certain consistencies of food, or food refusal, video cinefluoroscopy can be an extremely valuable study. Also called a modified barium swallow, the infant is given liquids and solids of varying consistency under the direction of a feeding therapist who collaborates with the radiologist to film the swallows. Subsequently, the film can be slowed down to evaluate the various phases of swallowing and document penetration and aspiration.

Procedures

Other diagnostic procedures may be appropriate and are performed as indicated.

A recent retrospective study on the indications for diagnostic upper endoscopy found that failure to thrive was among the top 3 conditions prompting this invasive investigation. The majority of children were found to have normal findings. The yield of identifying previously unrecognized problems that could have contributed to the failure to thrive was low and included gastritis (22%), esophagitis (14%), and celiac disease (2.6%).^[64]Frequently, physical findings and or a history are characteristic for acid peptic disease (gastritis, esophagitis, duodenitis, peptic ulcer) and can be treated empirically. Celiac disease can be suggested by positive tissue transglutaminase IgA, but present guidelines recommend biopsy to confirm the diagnosis.. A recent article from a medical school based feeding program found that virtually the only successful applications of endoscopic procedures was for children with medical diagnoses that were responsible for the FTT.^[63]

Treatment & Management

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Media Gallery

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.

of 5

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

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)

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 Academy of Pediatrics, American Association for the Advancement of Science, American College of Gastroenterology, American Gastroenterological Association, American Medical Association, New York Academy of Sciences, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Phi Beta Kappa, 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: Academy of Nutrition and Dietetics, 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, Society for Pediatric Research, Southern Society for Pediatric Research

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Nestle<br/>Serve(d) as a speaker or a member of a speakers bureau for: Nestle<br/>Received income in an amount equal to or greater than $250 from: Nestle.

Chief Editor

Additional Contributors

Maria Rebello Mascarenhas, MBBS Professor of Pediatrics, Perelman School of Medicine at the University of Pennsylvania; Section Chief of Nutrition, Division of Gastroenterology and Nutrition, Director, Nutrition Support Service, Medical Director, Integrative Health Program, Children's Hospital of Philadelphia

Maria Rebello Mascarenhas, MBBS is a member of the following medical societies: American Society for Parenteral and Enteral Nutrition, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Received research grant from: Kabi Fesinius<br/>Faculty member, DIGEST and member DSMB for: Cystic Fibrosis Foundation.

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