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

Sections

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

Bauchner H. Failure to Thrive. Nelson Textbook of Pediatrics. 18th Ed. Philadelphia, PA: WB Saunders; 2007. 37;184-7.
Frank DA, Zeisel SH. Failure to thrive. Pediatr Clin North Am. 1988 Dec. 35(6):1187-206. [Medline].
Porter B, Skuse D. When does slow weight gain become 'failure to thrive'?. Arch Dis Child. 1991 Jul. 66(7):905-6. [Medline].
Zenel JA Jr. Failure to thrive: a general pediatrician's perspective. Pediatr Rev. 1997 Nov. 18(11):371-8. [Medline].
Hoare KJ. A baby presenting with failure to thrive in primary care: a case report. Cases J. 2009. 2(1):137. [Medline].
Leung DH, Chung CT. Cases in pediatric gastroenterology from The Children's Hospital of Philadelphia: a 2-year-old boy with diarrhea, failure to thrive, and hepatomegaly. Medscape J Med. 2009. 11(1):13. [Medline].
Growth retardation indicators in children under 5 years old. Epidemiol Bull. 1998 Mar. 19 (1):13-6. [Medline].
Olsen EM, Petersen J, Skovgaard AM, et al. Failure to thrive: the prevalence and concurrence of anthropometric criteria in a general infant population. Arch Dis Child. 2007 Feb. 92(2):109-14. [Medline].
Mehta NM, Corkins MR, Lyman B, Malone A, Goday PS, Carney LN, et al. Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. JPEN J Parenter Enteral Nutr. 2013 Jul. 37 (4):460-81. [Medline].
Schwartz ID. Failure to thrive: an old nemesis in the new millennium. Pediatr Rev. 2000 Aug. 21 (8):257-64; quiz 264. [Medline].
Atalay A, McCord M. Characteristics of failure to thrive in a referral population: implications for treatment. Clin Pediatr (Phila). 2012 Mar. 51 (3):219-25. [Medline].
Larson-Nath CM, Goday PS. Failure to Thrive: A Prospective Study in a Pediatric Gastroenterology Clinic. J Pediatr Gastroenterol Nutr. 2016 Jun. 62 (6):907-13. [Medline].
Reilly SM, Skuse DH, Wolke D, Stevenson J. Oral-motor dysfunction in children who fail to thrive: organic or non-organic?. Dev Med Child Neurol. 1999 Feb. 41(2):115-22. [Medline].
Olsen EM, Skovgaard AM. [Psychosomatic failure-to-thrive in infants and toddlers]. Ugeskr Laeger. 2002 Nov 25. 164(48):5631-5. [Medline].
Skuse DH. Non-organic failure to thrive: a reappraisal. Arch Dis Child. 1985 Feb. 60(2):173-8. [Medline].
Manikam R, Perman JA. Pediatric feeding disorders. J Clin Gastroenterol. 2000 Jan. 30(1):34-46. [Medline].
Black MM, Tilton N, Bento S, Cureton P, Feigelman S. Recovery in Young Children with Weight Faltering: Child and Household Risk Factors. J Pediatr. 2016 Mar. 170:301-6. [Medline].
Manikam R, Perman JA. Pediatric feeding disorders. J Clin Gastroenterol. 2000 Jan. 30 (1):34-46. [Medline].
Field D, Garland M, Williams K. Correlates of specific childhood feeding problems. J Paediatr Child Health. 2003 May-Jun. 39 (4):299-304. [Medline].
Williams KE, Field DG, Seiverling L. Food refusal in children: a review of the literature. Res Dev Disabil. 2010 May-Jun. 31 (3):625-33. [Medline].
Yi SH, Joung YS, Choe YH, Kim EH, Kwon JY. Sensory Processing Difficulties in Toddlers With Nonorganic Failure-to-Thrive and Feeding Problems. J Pediatr Gastroenterol Nutr. 2015 Jun. 60 (6):819-24. [Medline].
Jung JS, Chang HJ, Kwon JY. Overall Profile of a Pediatric Multidisciplinary Feeding Clinic. Ann Rehabil Med. 2016 Aug. 40 (4):692-701. [Medline].
Wu YP, Franciosi JP, Rothenberg ME, Hommel KA. Behavioral feeding problems and parenting stress in eosinophilic gastrointestinal disorders in children. Pediatr Allergy Immunol. 2012 Dec. 23 (8):730-5. [Medline].
Dellon ES, Gonsalves N, Hirano I, Furuta GT, Liacouras CA, Katzka DA, et al. ACG clinical guideline: Evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE). Am J Gastroenterol. 2013 May. 108 (5):679-92; quiz 693. [Medline].
Rommel N, De Meyer AM, Feenstra L, Veereman-Wauters G. The complexity of feeding problems in 700 infants and young children presenting to a tertiary care institution. J Pediatr Gastroenterol Nutr. 2003 Jul. 37 (1):75-84. [Medline].
[Guideline] Centers for Disease Control and Prevention. CDC Growth Charts. August 4, 2009. [Full Text].
[Guideline] Cronk C, Crocker AC, Pueschel SM, et al. Growth charts for children with Down syndrome: 1 month to 18 years of age. Pediatrics. 1988 Jan. 81(1):102-10. [Medline].
[Guideline] Lyon AJ, Preece MA, Grant DB. Growth curve for girls with Turner syndrome. Arch Dis Child. 1985 Oct. 60(10):932-5. [Medline].
[Guideline] Horton WA, Rotter JI, Rimoin DL, Scott CI, Hall JG. Standard growth curves for achondroplasia. J Pediatr. 1978 Sep. 93(3):435-8. [Medline].
Daniel M, Kleis L, Cemeroglu AP. Etiology of failure to thrive in infants and toddlers referred to a pediatric endocrinology outpatient clinic. Clin Pediatr (Phila). 2008 Oct. 47(8):762-5. [Medline].
de Onis M, Blössner M, Borghi E, Frongillo EA, Morris R. Estimates of global prevalence of childhood underweight in 1990 and 2015. JAMA. 2004 Jun 2. 291 (21):2600-6. [Medline].
Levels & Trends in Child Malnutrition: UNICEF-WHO-The World Bank Joint Child Malnutrition Estimates. WHO. Available at http://www.who.int/nutgrowthdb/summary_jme_2013.pdf?ua=1. 2014; Accessed: December 1, 2016.
Rudolf MC, Logan S. What is the long term outcome for children who fail to thrive? A systematic review. Arch Dis Child. 2005 Sep. 90(9):925-31. [Medline].
Drewett RF, Corbett SS, Wright CM. Cognitive and educational attainments at school age of children who failed to thrive in infancy: a population-based study. J Child Psychol Psychiatry. 1999 May. 40(4):551-61. [Medline].
Prazuck T, Tall F, Nacro B, et al. HIV infection and severe malnutrition: a clinical and epidemiological study in Burkina Faso. AIDS. 1993 Jan. 7(1):103-8. [Medline].
Lechner-Gruskay D, Honig PJ, Pereira G, McKinney S. Nutritional and metabolic profile of children with epidermolysis bullosa. Pediatr Dermatol. 1988 Feb. 5(1):22-7. [Medline].
Reif S, Beler B, Villa Y, Spirer Z. Long-term follow-up and outcome of infants with non-organic failure to thrive. Isr J Med Sci. 1995 Aug. 31(8):483-9. [Medline].
Corbett SS, Drewett RF. To what extent is failure to thrive in infancy associated with poorer cognitive development? A review and meta-analysis. J Child Psychol Psychiatry. 2004 Mar. 45(3):641-54. [Medline].
Emond AM, Blair PS, Emmett PM, Drewett RF. Weight faltering in infancy and IQ levels at 8 years in the Avon Longitudinal Study of Parents and Children. Pediatrics. 2007 Oct. 120(4):e1051-8. [Medline].
Mackner LM, Starr RH Jr, Black MM. The cumulative effect of neglect and failure to thrive on cognitive functioning. Child Abuse Negl. 1997 Jul. 21(7):691-700. [Medline].
DeBoer MD, Lima AA, Oría RB, Scharf RJ, Moore SR, Luna MA, et al. Early childhood growth failure and the developmental origins of adult disease: do enteric infections and malnutrition increase risk for the metabolic syndrome?. Nutr Rev. 2012 Nov. 70(11):642-53. [Medline]. [Full Text].
Kim GJ, Furman LM. Obesity Outcomes in Children With a History of Failure to Thrive. Clin Pediatr (Phila). 2013 May 15. [Medline].
Hoddinott J, Behrman JR, Maluccio JA, et al. Adult consequences of growth failure in early childhood. Am J Clin Nutr. 2013 Nov. 98(5):1170-8. [Medline]. [Full Text].
Berwick DM, Levy JC, Kleinerman R. Failure to thrive: diagnostic yield of hospitalisation. Arch Dis Child. 1982 May. 57(5):347-51. [Medline].
Genero A, Moretti C, Fait P, Guariso G. [Non-organic failure to thrive: retrospective study in hospitalized children]. Pediatr Med Chir. 1996 Sep-Oct. 18(5):501-6. [Medline].
Homer C, Ludwig S. Categorization of etiology of failure to thrive. Am J Dis Child. 1981 Sep. 135(9):848-51. [Medline].
Crossin R, Cairney S, Lawrence AJ, Duncan JR. Adolescent inhalant abuse leads to other drug use and impaired growth; implications for diagnosis. Aust N Z J Public Health. 2016 Oct 23. [Medline].
Yoo SD, Hwang EH, Lee YJ, Park JH. Clinical Characteristics of Failure to Thrive in Infant and Toddler: Organic vs. Nonorganic. Pediatr Gastroenterol Hepatol Nutr. 2013 Dec. 16(4):261-8. [Medline]. [Full Text].
Oates RK. Similarities and differences between nonorganic failure to thrive and deprivation dwarfism. Child Abuse Negl. 1984. 8(4):439-45. [Medline].
Skuse DH. Non-organic failure to thrive: a reappraisal. Arch Dis Child. 1985 Feb. 60(2):173-8. [Medline].
Shams N, Mostafavi F, Hassanzadeh A. Determinants of complementary feeding practices among mothers of 6-24 months failure to thrive children based on behavioral analysis phase of PRECEDE model, Tehran. J Educ Health Promot. 2016 Jun 23. 5:24. [Medline].
Wu YP, Franciosi JP, Rothenberg ME, Hommel KA. Behavioral feeding problems and parenting stress in eosinophilic gastrointestinal disorders in children. Pediatr Allergy Immunol. 2012 Dec. 23 (8):730-5. [Medline].
Vohr BR, Stephens BE, McDonald SA, et al. Cerebral palsy and growth failure at 6 to 7 years. Pediatrics. 2013 Oct. 132(4):e905-14. [Medline]. [Full Text].
Schwarz SM, Corredor J, Fisher-Medina J, Cohen J, Rabinowitz S. Diagnosis and treatment of feeding disorders in children with developmental disabilities. Pediatrics. 2001 Sep. 108(3):671-6. [Medline].
Tannenbaum GS, Ramsay M, Martel C, Samia M, Zygmuntowicz C, Porporino M. Elevated circulating acylated and total ghrelin concentrations along with reduced appetite scores in infants with failure to thrive. Pediatr Res. 2009 May. 65(5):569-73. [Medline].
Wali P, King J, He Z, Tonb D, Horvath K. Ghrelin and obestatin levels in children with failure to thrive and obesity. J Pediatr Gastroenterol Nutr. 2014 Mar. 58(3):376-81. [Medline].
Velasco P, Clemente M, Lorite R, et al. The role of leptin in diencephalic syndrome. Pediatrics. 2014 Jan. 133(1):e263-6. [Medline].
Järvinen KM, Nowak-Wegrzyn A. Food protein-induced enterocolitis syndrome (FPIES): current management strategies and review of the literature. J Allergy Clin Immunol Pract. 2013 Jul-Aug. 1(4):317-22. [Medline].
Puls HT, Hall M, Bettenhausen J, Johnson MB, Peacock C, Raphael JL, et al. Failure to Thrive Hospitalizations and Risk Factors for Readmission to Children's Hospitals. Hosp Pediatr. 2016 Aug. 6 (8):468-75. [Medline].
Wright CM, Garcia AL. Child undernutrition in affluent societies: what are we talking about?. Proc Nutr Soc. 2012 Nov. 71(4):545-55. [Medline].
Mash C, Frazier T, Nowacki A, Worley S, Goldfarb J. Development of a risk-stratification tool for medical child abuse in failure to thrive. Pediatrics. 2011 Dec. 128(6):e1467-73. [Medline].
Sills RH. Failure to thrive. The role of clinical and laboratory evaluation. Am J Dis Child. 1978 Oct. 132(10):967-9. [Medline].
Larson-Nath CM, Goday PS. Failure to Thrive: A Prospective Study in a Pediatric Gastroenterology Clinic. J Pediatr Gastroenterol Nutr. 2016 Jun. 62 (6):907-13. [Medline].
Sheiko MA, Feinstein JA, Capocelli KE, Kramer RE. Diagnostic yield of EGD in children: a retrospective single-center study of 1000 cases. Gastrointest Endosc. 2013 Jul. 78(1):47-54.e1. [Medline].
Thompson RT, Bennett WE Jr, Finnell SM, Downs SM, Carroll AE. Increased length of stay and costs associated with weekend admissions for failure to thrive. Pediatrics. 2013 Mar. 131(3):e805-10. [Medline].
Hyman P. Role of Development in Infant and Toddler Food Refusal. SIG 13 Perspectives on Swallowing and Swallowing Disorders (Dysphagia). October 2010. 19:64-67.
Arvedson J, Brodsky L. Pediatric Swallowing and Feeding , Assessment and Management. Second Edition. Singular Publishing Co.; 2002.
American Speech-Language-Hearing Association. Roles of speech-language pathologists in swallowing and feeding disorders: Position statement. 2002. ASHA Supplement 22:73.
Williams KE, Field DG, Seiverling L. Food refusal in children: a review of the literature. Res Dev Disabil. 2010 May-Jun. 31 (3):625-33. [Medline].
Piazza CC, Carroll-Hernandez TA. Assessment and Treatment of Pediatric Feeding Disorders. Encyclopedia on Early Childhood Development. March 11, 2004. 1-7. [Full Text].
Addison LR, Piazza CC, Patel MR, Bachmeyer MH, Rivas KM, Milnes SM, et al. A comparison of sensory integrative and behavioral therapies as treatment for pediatric feeding disorders. J Appl Behav Anal. 2012 Fall. 45 (3):455-71. [Medline].
Seiverling L, Kokitus A, Williams K. A clinical demonstration of a treatment package for food selectivity. The Behavior Analyst Today. 2012. 13(2):11-16.
Seiverling L, Harclerode W, Williams KE. The Effects of a Modified Treatment Package With and Without Feeder Modeling on One Child's Acceptance of Novel Foods. Education and Treatment of Children. August 2014. 37(3):477-493.
Williams KE, Seiverling LJ. The assessment and treatment of feeding problems among children with autism spectrum disorders. Patel VB, Preedy VR, Marin CR. Comprehensive Guide to Autism. Springer; 1973-1993.
Black MM, Tilton N, Bento S, Cureton P, Feigelman S. Recovery in Young Children with Weight Faltering: Child and Household Risk Factors. J Pediatr. 2016 Mar. 170:301-6. [Medline].
Bentovim A, Elliott I. Hope for children and families: targeting abusive parenting and the associated impairment of children. J Clin Child Adolesc Psychol. 2014. 43(2):270-85. [Medline].
Maggioni A, Lifshitz F. Nutritional management of failure to thrive. Pediatr Clin North Am. 1995 Aug. 42(4):791-810. [Medline].
Black MM, Dubowitz H, Krishnakumar A, Starr RH Jr. Early intervention and recovery among children with failure to thrive: follow-up at age 8. Pediatrics. 2007 Jul. 120(1):59-69. [Medline].
Black MM, Dubowitz H, Hutcheson J, Berenson-Howard J, Starr RH Jr. A randomized clinical trial of home intervention for children with failure to thrive. Pediatrics. 1995 Jun. 95(6):807-14. [Medline].

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.

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