Management Failure to thrive in Infant and Children

Management Failure to thrive in Infant and Children

Children are diagnosed with failure to thrive when their weight or rate of weight gain is significantly below that of other children of similar age and gender. Infants or children that fail to thrive seem to be dramatically smaller or shorter than other children the same age. Teenagers may have short stature or appear to lack the usual changes that occur at puberty. However, there is a wide variation in what is considered normal growth and development.

Failure to thrive (FTT) is a medical term which is used in both pediatric and adult human medicine, as well as veterinary medicine (where it is also referred to as ill thrift). When not more precisely defined, the term refers to pediatric patients. In MeSH, the term is assumed to refer to an infant or child. In children, it is usually defined in terms of weight, and can be evaluated either by a low weight for the child’s age, or by a low rate of increase in the weight. Failure to thrive refers to children whose current weight or rate of weight gain is significantly lower than that of other children of similar age and gender.

Infantile AND pediatric failure to thrive

As used by pediatricians, it covers poor physical growth of any cause and does not imply abnormal intellectual, social, or emotional development, although of course it can subsequently be a cause of such pathologies. The term has been used in different ways,[4] and different objective standards have been defined.[5][6] Many definitions use the 5th percentile as a cutoff.

Traditionally, causes of FTT have been divided into endogenous and exogenous causes. Initial investigation should consider physical causes, calorie intake and psychosocial assessment.

  • endogenous (or “organic”): Causes are due to physical or mental issues with the child himself. It can include various inborn error of metabolism. Problems with the gastrointestinal system such as gas and acid reflux are painful conditions which may make the child unwilling to take in sufficient nutrition. Cystic fibrosis, diarrhea, liver disease, and celiac disease make it more difficult for the body to absorb nutrition. Other causes include physical deformities such as cleft palate and tongue tie. Milk allergies can cause endogenous FTT. Also the metabolism may be raised by parasites, asthma, urinary tract infections (UTIs) and other fever inducing infections, or heart disease so that it becomes difficult to get in sufficient calories to meet the higher caloric demands.
  • exogenous (or “nonorganic”): Caused by caregivers actions. Examples include physical inability to produce enough breastmilk, using only babies cues to regulate breastfeeding so as to not offer a sufficient numbers of feeds (sleepy baby syndrome),[8], inability to procure formula when needed, purposely limiting total caloric intake (often for what the caregiver views as a more aesthetically pleasing child), and not offering sufficient age-appropriate solid foods for babies and toddlers over the age of 6 months.
  • Mixed: However, to think of the terms as dichotomous can be misleading, since both endogenous and exogenous factors may co-exist. For instance a child who is not getting sufficient nutrition may act content so that caregivers do not offer feedings of sufficient frequency or volume, and a child with severe acid reflux who appears to be in pain while eating may make a caregiver hesitant to offer sufficient feedings.

Recently the term ‘faltering growth’ has become a popular replacement for ‘failure to thrive’, which in the minds of some represents a more euphemistic term

Causes

This is a general diagnosis, with many possible causes. Common to all cases, though, is the failure to gain weight as expected, often accompanied by poor height growth. Diagnosing and treating a child who fails to thrive focuses on identifying any underlying problem. From there, doctors and the family work together to get the child back into a healthy growth pattern.

Failure to thrive (nonorganic, NOFTT; also called psychosocial failure to thrive) is defined as decelerated or arrested physical growth (height and weight measurements fall below the fifth percentile, or a downward change in growth across two major growth percentiles) associated with poor developmental and emotional functioning. Organic failure to thrive occurs when there is an underlying medical cause. Nonorganic (psychosocial) failure to thrive occurs in a child who is usually younger than 2 years old and has no known medical condition that causes poor growth.

Psychological, social, or economic problems within the family almost always play a role in the cause of NOFTT. Emotional or maternal deprivation is often related to the nutritional deprivation. The mother or primary caregiver may neglect proper feeding of the infant because of preoccupation with the demands or care of others, her own emotional problems, substance abuse, lack of knowledge about proper feeding, or lack of understanding of the infant’s needs. Organic failure to thrive is caused by medical complications of premature birth or other medical illnesses that interfere with feeding and normal bonding activities between parents and infants.

It is important to determine whether failure to thrive results from medical problems or factors in the environment, such as abuse or neglect.

There are many medical causes of failure to thrive. These include:

  • Chromosome problems such as Down syndrome and Turner syndrome
  • Organ problems
  • Thyroid hormone deficiency, growth hormone deficiency, or other hormone deficiencies
  • Damage to the brain or central nervous system, which may cause feeding difficulties in an infant
  • Heart or lung problems, which can affect how nutrients move through the body
  • Anemia or other blood disorders
  • Gastrointestinal problems that make it hard to absorbe nurtients or cause the body to have a lack of digestive enzymes
  • Long-term gastroenteritis and gastroesophageal reflux (usually temporary)
  • Cerebral palsy
  • Long-term (chronic) infections
  • Metabolic disorders
  • Complications of pregnancy and low birth weight

Other factors that may lead to failure to thrive:

  • Emotional deprivation as a result of parental withdrawal, rejection, or hostility
  • Poverty
  • Problems with child-caregiver relationship
  • Parents do not understand the appropriate diet needs for their the child
  • Exposure to infections, parasites, or toxins
  • Poor eating habits, such as eating in front of the television and not having formal meal times

Many times the cause cannot be determined.

Symptoms

In general, the rate of change in weight and height may be more important than the actual measurements. Infants or children who fail to thrive have a height, weight, and head circumference that do not match standard growth charts. The person’s weight falls lower than 3rd percentile (as outlined in standard growth charts) or 20% below the ideal weight for their height. Growing may have slowed or stopped after a previously established growth curve.

Children that fail to thrive seem to be much smaller or shorter than other children the same age. Teenagers may not appear to have the usual changes that occur at puberty. However, it’s important to remember that the way children grow and develop varies quite a bit.

Symptoms of failure to thrive include:

  • lack of appropriate weight gain
  • irritability
  • easily fatigued
  • excessive sleepiness
  • lack of age-appropriate social response (i.e., smile)
  • avoids eye contact
  • lack of molding to the mother’s body
  • does not make vocal sounds
  • delayed motor development
  • Height, weight, and head circumference do not match standard growth charts.
  • Weight is lower than 3rd percentile (as outlined in standard growth charts) or 20% below the ideal weight for their height.
  • Growth may have slowed or stopped after a previously established growth curve.

In general, the child’s rate of change in weight and height may be more important than the actual growth measurements.

Children who fail to thrive may have the following delayed or slow to develop:

  • Physical skills such as rolling over, sitting, standing and walking
  • Mental and social skills
  • Secondary sexual characteristics (delayed in adolescents)

Babies who fail to gain weight or develop often have a lack of interest in feeding or a problem receiving the proper amount of nutrition. This is called “poor feeding.”

Other symptoms that may be seen in a child that fails to thrive include:

  • Constipation
  • Excessive crying
  • Excessive sleepiness (lethargy)
  • Irritability

Diagnosis

Failure to thrive is usually discovered and diagnosed by the infant’s physician. Infants are always weighed and measured when seen by their physicians for well-baby check-ups. The physician initiates a more complete evaluation when the infant’s development and functioning are found to be delayed.

The doctor will perform a physical exam and check the child’s height, weight, and body shape. You will be asked questions about the child’s medical and family history.

A special test called the Denver Developmental Screening Test will be used to show any delays in development. A growth chart outlining all types of growth since birth is created.

It is important to determine whether failure to thrive results from medical problems or factors in the environment, such as abuse or neglect.

There are multiple medical causes of failure to thrive. These include:

  • Chromosome abnormalities such as Down syndrome and Turner syndrome
  • Defects in major organ systems
  • Problems with the endocrine system, such as thyroid hormone deficiency, growth hormone deficiency, or other hormone deficiencies
  • Damage to the brain or central nervous system, which may cause feeding difficulties in an infant
  • Heart or lung problems, which can affect how oxygen and nutrients move through the body
  • Anemia or other blood disorders
  • Gastrointestinal problems that result in malabsorption or a lack of digestive enzymes
  • Long-term gastroenteritis and gastroesophageal reflux (usually temporary)
  • Cerebral Palsy
  • Long-term (chronic) infections
  • Metabolic disorders
  • Complications of pregnancy and low birth weight

Other factors that may lead to failure to thrive:

  • Emotional deprivation as a result of parental withdrawal, rejection, or hostility
  • Economic problems that affect nutrition, living conditions, and parental attitudes
  • Exposure to infections, parasites, or toxins
  • Poor eating habits, such as eating in front of the television and not having formal meal times

Many times the cause cannot be determined.

The following tests may be done:

  • Complete blood count (CBC)
  • Electrolyte balance
  • Hemoglobin electrophoresis to check for conditions such as sickle cell disease
  • Hormone studies, including thyroid function tests
  • X-rays to determine bone age
  • Urinalysis

Treatment

  • Treatment depends on the cause of the delayed growth and development. Delayed growth due to nutritional factors can be helped by showing the parents how to provide a well-balanced diet. Do not give your child dietary supplements such as Boost or Ensure without talking to your health care provider first.
  • The treatment depends on the cause of the delayed growth and development. Delayed growth due to nutritional factors can be resolved by educating the parents to provide a well-balanced diet.
  • If psychosocial factors are involved, treatment should include improving the family dynamics and living conditions. Parental attitudes and behavior may contribute to a child’s problems and need to be examined. In many cases, a child may need to be hospitalized initially to focus on implementation of a comprehensive medical, behavioral, and psychosocial treatment plan.
  • Do not give your child dietary supplements without consulting your physician first.

Specific treatment for failure to thrive will be determined by your child’s physician based on:

  • your child’s age, overall health, and medical history
  • extent of your child’s symptoms
  • cause of the condition
  • your child’s tolerance for specific medications, procedures, or therapies
  • expectations for the course of the condition
  • your opinion or preference

The first year of life is an important time for brain growth. Children with NOFTT that are not treated for an extended period of time may have difficulty “catching up” developmentally and socially. About 50 percent of children who experienced failure to thrive as an infant or young child continue to have social and emotional problems or eating problems later in life. The individual issues involved in causing NOFTT are almost always complex. Treatment planning usually requires the involvement of a pediatrician, nutritionist, social worker, physical or occupational therapist, and a psychiatrist or other qualified mental health provider.

Other treatment depends on the severity of the condition. The following may be recommended:

  • Increase the number of calories and amount of fluid the infant receives
  • Correct any vitamin or mineral deficiencies
  • Identify and treat any other medical conditions

The child may need to stay in the hospital for a little while.

Treatment may also involve improving the family relationships and living conditions. Sometimes, the parent’s attitudes and behavior may contribute to a child’s failure to thrive.

Normal growth and development may be affected if a child fails to thrive for a long time.

Normal growth and development may continue if the child has failed to thrive for a short time, and the cause is determined and treated.

Possible Complications

Permanent mental, emotional, or physical delays can occur.

When to Contact a Medical Professional

Call for an appointment with your health care provider if your child does not seem to be developing normally.

Prevention

  • Regular check-ups can help detect failure to thrive in children.
  • NOFTT occurs because of social, emotional, economic, and interpersonal problems. Community efforts to educate and encourage people to seek help for their problems may help to reduce the incidence of NOFTT. Encouraging parenting education courses in high school and educational and community programs may help new parents enter parenthood with an increased knowledge of an infant’s needs. Early detection and intervention can reduce the severity of symptoms, enhance the process of normal growth and development, and improve the quality of life experienced by infants and children

Alternative Names

Growth failure; FTT; Feeding disorder; Poor feeding

References

  • McLean HS, Price DT. Failure to thrive. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 38.

 

 

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