Failure to Thrive

Failure to Thrive (FTT) consensus on definition lacking

  • Consider if weight <2%ile for gestation-corrected age and sex and decreased velocity of weight gain that is disproportionate to growth in length

Causes

  • Inadequate intake
    • Eating poorly (most common)
    • Anorexia associated with chronic disease
    • Eating/oral skills lacking
  • Inadequate absorption
    • Emesis
    • Malabsorption
      • Pancreatic disease (Cystic fibrosis, Scwachman-Diamond syndrome)
      • Cholestatic liver disease
      • Intestinal disase (celiac, Crohn's)
  • Excessive caloric expenditure
    • Chronic disease/infections
    • Endocrine
      • Hypothyroidism
      • Growth hormone deficiency
  • Other (rare)
    • Diencephalic tumour
    • Renal tubular acidosis

History

  • Age of Onset
  • Food
    • Preferences, restrictions
    • Timing
    • Environment, distractions
  • Medical history
    • Pre/perinatal history (IUGR, LBW, prematurity)
    • Medications
    • Consider immunodeficiency if frequent infections
    • Consider neglect/abuse if frequent injuries
  • Family history
    • Mid-parental height can be calculated to estimate a child’s genetic potential:
      • Boys: (father’s height + mother’s height) / 2 + 6.5 cm +/- 8.5 cm
      • Girls: (father’s height + mother’s height) / 2 - 6.5 cm +/- 8.5 cm
  • Psychosocial stressors (poverty, family discord, neglect)
  • Review of systems
    • Vomiting, diarrhea, constipation
    • Abdominal pain
    • Decreased appetite
    • Travel
    • Infections
    • Wheezing
    • Polyuria, polydipsia, polyphagia (diabetes)

On Examination

  • Vitals
  • Growth (weight, length/height, head circumference)
  • Signs of dehydration
  • Cardiorespiratory
  • Abdominal (organomegaly)
  • Development/behaviour

Red Flags

  • Cardiac findings suggesting congenital heart disease or heart failure (e.g., tachycardia, cyanosis/hypoxemia, murmur, edema, hepatomegaly)
  • Developmental delay
  • Dysmorphic features
  • Failure to gain weight despite adequate caloric intake
  • Organomegaly or lymphadenopathy
  • Recurrent or severe respiratory, mucocutaneous, or urinary infection
  • Recurrent vomiting, diarrhea, or dehydration

Consider initial work-up

  • CBC (anemia, chronic infection, inflammation, and malignancy)
  • Urinalysis (glucosuria, renal disease)
  • Electrolytes
  • Blood urea nitrogen
  • Liver enzymes
  • Lead testing
  • CRP/ESR
  • Anti- TTG and Total IgA (celiac)

Management

  • Lactation consultant if a breast feeding problem
  • Nutritional counselling
    • Increase caloric intake
    • Reduce liquid (milk/juice) intake
    • Changes to the feeding environment
      • Regular schedule with frequent snacks
      • Use positive reinforcement (avoid forced feeding)
      • Limit distractions (TV)
      • Eat as a family
      • Ensure access to food (high chair or small table)

Referral

  • Pediatric interdisciplinary team