7-Failure To Thrive

FAILURE TO THRIVE
Learning Objectives
■ By the end of this lecture, the student should be able to:
– Define FTT
– Describe the normal growth pattern in full term & pre-term infants
– Plot growth parameters on growth charts
– List the important points in the history (risk factors)
– List the important physical signs on examination.
– Know the classification of FTT
– Know non-organic FTT
– List the causes of organic FTT
– List the differential diagnosis
– List the lab tests.
– List the imaging studies
– Describe the dietary managements
– Describe the monitoring indices.
Introduction
■ Growth is determined by plotting serial measurements of
weight, length or height, and head circumference, using the
WHO growth charts for boys or girls.
■ Failure to thrive (TOT) or Weight faltering is suboptimal
weight gain in infants or young children.
■ If prolonged and severe, it will result in reduction in height or
length (stunting) and reduction in head growth and may be
associated with delayed development.
Introduction
■ Healthy children's weight will fluctuate, but it will usually progress within
one centile space.
■ size at birth is determined not only by genes but also by the intrauterine
environment.
■ Over the first few weeks, infants who are large at birth will often cross
down centiles (catch-down growth), whereas small babies will move up
centiles (catch-up growth) to find their genetic centile growth lines.
■ Infants who become acutely ill will often lose weight, but will regain their
weight centile within 2 to 3 weeks.
Identifying weight faltering
■ Weight faltering describes a sustained drop down two centile
spaces.
■ A single observation of weight is difficult to interpret unless
markedly discrepant from the head circumference or length.
■ All babies should be weighed during the 1st week, and then at
around 8, 12, and 16 weeks, then at 1 year, and whenever
concerns are raised.
■ the further the weight is below the second centile, the more
likely the child is ‘weight faltering’.
Identifying weight faltering
■ Any child whose weight crosses two centile lines or is below the 0.4th
centile or has a body mass index (BMI) less than the second centile
should be evaluated.
■ The infant with growth faltering needs to be differentiated from a normal
but small or thin baby.
■ If the child was born preterm, this should be allowed for when plotting
growth during the first 1–2 years of age, depending on the degree of
prematurity.
■ Some infants with severe intrauterine growth restriction remain small,
though most exhibit catch-up growth.
failure to thrive constitutionally small infant
Causes
■ In most, the cause is inadequate intake of food, but the reason for this is often
multifactorial.
■ the causes have been divided into:
■ ‘organic’ causes: found in 5% to 10%, and there are almost always
symptoms and signs pointing to the underlying disease.
■ ‘nonorganic’ causes: Although weight faltering is often considered to be
a manifestation of poverty (and is certainly true in poorer societies),
studies in the UK have not found an association with low socioeconomic
status or poor educational attainment.
■ Neglect and child abuse must always be considered, it account for 5% of
cases.
Clinical features and investigation
If weight faltering is confirmed, a dietary history should be taken

to include:
• history of milk feeding
• age at weaning
• range and type of foods now taken
• mealtime routine and eating and feeding behaviours
• a 3-day food diary will provide a more detailed and accurate
picture of intake
• if possible, observe a meal being taken
Consider also:
■ was the child born preterm or had intrauterine growth
restriction?
■ is the child well with lots of energy or does the child have other
symptoms such as diarrhoea, vomiting, cough, or lethargy?
■ the growth of other family members and any illnesses in the
family
■ is the child's development normal?
■ are there psychosocial problems at home?
– If organic disease is the cause, suggestive symptoms and signs are
usually present.
Examination:
■ should focus on identifying signs of organic disease, such as:
– dysmorphic features,
– signs suggestive of malabsorption (distended abdomen, thin buttocks,
misery),
– signs suggestive of chronic respiratory disease,
– signs of heart failure and
– evidence of nutritional deficiencies (koilonychia, angular stomatitis).
Investigations
■ In some children with growth faltering, a full blood count and serum
ferritin may be helpful to identify iron-deficiency anaemia. This is usually
secondary to inadequate iron intake and correcting it may improve
appetite.
■ In most instances, no investigations are required.
■ Further information about the child and family from the health visitor,
general practitioner or other professionals involved with the family can be
particularly helpful.
Investigations to be considered in weight faltering in a child with worrying signs or symptoms of
disease
Investigation Interpreting result
Full blood count and differential white cell count Anaemia, neutropenia, lymphopenia (immune deficiency)
Serum creatinine, urea, electrolytes, acid–base Renal failure, renal tubular acidosis, metabolic disorders, William syndrome
status, calcium, phosphate

Liver function tests Liver disease, malabsorption, metabolic disorders
Thyroid function tests Hypothyroidism or hyperthyroidism
Acute phase reactant, e.g. CRP (C-reactive Inflammation
protein)
Ferritin Iron-deficiency anaemia
Immunoglobulins Immune deficiency
IgA tTG (IgA tissue transglutaminase antibodies) Coeliac disease
Urine microscopy, culture, and dipsticks Urinary tract infection, renal disease
Stool microscopy, culture, and elastase Intestinal infection, parasites, elastase decreased in pancreatic insufficiency
Karyotype in girls Turner syndrome
Sweat test, chest X-ray Cystic fibrosis, other respiratory disorders

Management
■ The management of most weight faltering is carried out in primary care.
■ Using mealtime observations and food diaries,
■ health visitors can assess and support families to improve feeding and
increase calorie intake.
■ Access to specialist support may be required.
■ A paediatric dietician is helpful in assessing the quantity and

composition of food intake,
Management
■ recommending strategies for increasing energy intake and a speech and
language therapist has specialist skills with feeding disorders.
■ Input from a clinical psychologist and from social services may also be
needed.
■ Nursery placement can be helpful in alleviating stress at home and
assisting with feeding.
■ The key outcome measure is a rise up the weight centiles; this usually
begins 4 weeks to 8 weeks after intervention.
Management
■ In children under 6 months of age with severe weight faltering,
hospital admission may occasionally be necessary for active
refeeding and multidisciplinary team involvement.
■ While being on a children's ward may offer the opportunity to
observe and improve the parent's method and skill in feeding,
■ In extreme circumstances, hospital admission can be used to
demonstrate that the child will gain weight when fed
appropriately.
Outcome
■ Weight faltering appears to have a long-term effect on growth, with
children remaining on a low centile.
■ However, a randomized controlled trial of primary care intervention
has shown that, at 4 years of age, children who received intervention
were heavier and taller than untreated controls.
■ Weight faltering also appears to have an adverse effect on cognition,
although this is small.
■ Some children continue to under eat.
SUMMARY
■ Weight faltering or failure to thrive Is a description, not a diagnosis.
■ Weights of infants are only helpful if measured accurately and plotted on an
appropriate centile growth chart.
■ Is present if an infant's weight falls across two centile spaces.
■ Is more likely to be present the further the weight is below the second centile.
■ Although complex in origin and multifactorial, the final common pathway is
inadequate food intake.
■ If there is underlying pathology, it is almost always accompanied by abnormal
symptoms or signs.
■ Most affected infants and toddlers do not require any investigations and are
managed in primary care by dietary and behavioural modification designed to
increase energy intake and monitoring growth.
Strategies for increasing energy intake
Dietary
■ Three meals and two snacks each day
■ Increase number and variety of foods offered
■ Increase energy density of foods (e.g. add cheese, margarine, cream)
■ Limit milk intake to 500 ml/day
■ Avoid excessive intake of fruit juice and squash

Strategies for increasing energy intake
Behavioural
■ Offer meals at regular times with other family members
■ Praise when food is eaten, ignore when not
■ Limit mealtime to 30 minutes
■ Eat at same time as child
■ Avoid mealtime conflict
■ Never force feed
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FAILURE TO THRIVE

If weight faltering is confirmed, a dietary history should be taken

status, calcium, phosphate

Thyroid function tests Hypothyroidism or hyperthyroidism

Acute phase reactant, e.g. CRP (C-reactive Inflammation

Immunoglobulins Immune deficiency

IgA tTG (IgA tissue transglutaminase antibodies) Coeliac disease

Karyotype in girls Turner syndrome

Sweat test, chest X-ray Cystic fibrosis, other respiratory disorders

■ Using mealtime observations and food diaries,

■ Access to specialist support may be required.

■ A paediatric dietician is helpful in assessing the quantity and

■ Three meals and two snacks each day

■ Increase number and variety of foods offered

■ Increase energy density of foods (e.g. add cheese, margarine, cream)

■ Limit milk intake to 500 ml/day

■ Avoid excessive intake of fruit juice and squash

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