(Pediatr Rev 2000;21:257; Am Fam Physician 2003;68:879; Clin Fam Pr 2003;5:293;
Pediatr Rev 2006;27:e1; Pediatr Rev 2011;32:100)
Introduction
• No standard dx criteria exist; failure to thrive (FTT) most commonly defined as decel growth across 2 major percentile lines, or weight for age less than 5th percentile
• Challenging to interpret: Crossing 2 major percentile curves (either ↑ or ↓) found to be common btw birth to 6 mo of age (32–39% of Californian infants), less common btw 6–24 mo (6–15%), & least common btw 24–60 mo (1–10%). Shifts in weight-for-height occurred nearly twice as frequently (Pediatrics 2004;113:e617)
• 1° etiology is malnutrition, 2/2 multi medical, behavioral, psychosocial, & environ causes
• Malnourishment 1st decreases weight, then height, then head circumference
• Decreased height growth suggests congenital, genetic, or endocrine abnormality
• Proportional decrease in height and weight suggests underlying chronic medical condition
Etiology
• Inadequate caloric intake
• Incorrect formula prep or breast-feeding challenges, difficulty transitioning to table food, excessive juice intake
• Mech feeding diff (anatomic, oral lesions), motor diff (oromotor dysfxn, CNS dz)
• Familial dysfxn, disturbed parent–child relationship (neglect or hypervigilance)
• Poverty and food insecurity
• Inadequate absorption
• Milk protein allergy, GERD, vit or mineral (acrodermatitis enteropathica, scurvy)
• CF, Celiac disease, IBD, biliary atresia, or liver disease
• Chronic toddler diarrhea, infectious diarrhea
• Necrotizing enterocolitis or short-gut syndrome
• Increased metabolic demand
• Hyperthyroidism, growth hormone deficiency, hypercortisolism, pituitary insufficiency, diencephalic syndrome, insulin resistance (IUGR)
• Hypoxemia (congenital heart disease, chronic lung disease, tonsillar hypertrophy)
• Chronic infection (TORCH, HIV, TB, immunodeficiency)
• Malignancy or renal disease
• Genetic abn (Trisomy 21, 18, 13, Russell–Silver, Prader–Willi, Cornelia de Lange)
• Metabolic disorders (storage diseases, amino acid disorders)
Clinical Manifestations
• Plot weight, height, and head circumference at every visit; assess trend
• Detailed history: Diet, types of foods, & eating behaviors
• PMH: Birth history (premature, SGA, IUGR, short gut), newborn genetic screen
• FHx: Stature of family members, FTT, mental illness, eating disorders, resp or GI dz
• SHx: Caregivers, family support, stressors (economic, intrafamilial, major life events), substance abuse, child protective service involvement
• PE: Dysmorphic features, evid. of underlying dz, signs of abuse/neglect
• Assess severity of malnutrition
• Observe interactions between parent and child, especially during feeding
Diagnostic Studies
• Review 3 d food diary
• Consider referrals (GI, nutrition, feeding eval, OT, PT, SW, psych, genetics)
• No routine lab tests are indicated, unless suggested by the history or physical exam
• General tests to consider include CBC, Chem20, U/A, fecal fat, stool guaiac, sweat chloride test, celiac testing (total IgA, Tissue Transglutaminase (TTG) IgA)
Management
• Outpatient: Dependent upon etiology of FTT
• Feeding behavior mod w/ high-calorie diet (catch-up growth)
• 120 kcal/kg × (median weight in kg/current weight in kg) = kcal needed
• Usually 1.5–2× recom daily caloric intake; catch-up weight precedes height
• Suppl cals w/ conc. formulas, high-cal milk drinks (PediaSure), calorie-rich foods
• MVI w/ iron and zinc
• Structure mealtime
• Inpatient: Pts w/ severe malnutrition (weight <60% of ideal, hypothermia, bradycardia, or HoTN), electrolyte abn, dehydration, failure to achieve catch-up growth w/ outpt mgmt, or if concern for child safety
• Most children resume growth w/ intervention within wks to mos, may require supplemental enteral feeds to increase rapidity of growth