Failure to Thrive in

childen Adnan Aljothery

Professor and Consultant Pediatrician

Agenda

Definition

Prevalence

Etiology

Diagnostic Evaluation

Treatment

Prognosis and Outcomes

Prevention

Definition

• FTT is a significantly prolonged

cessation of appropriate weight gain

compared with recognized norms for

age and gender.

Fall over 2 or more percentiles. or

Persistently below the third or fifth

percentiles.

Common Anthropometric Criteria for

Diagnosing Failure to Thrive

Body mass index for age less than the 5th percentile.

Length for age less than the 5th percentile.

Weight deceleration crossing two major percentile

lines

Weight for age less than the 5th percentile.

A Weight velocity less than the 5th percentile

There is no consensus on which specific anthropometric

criteria should be used to define FTT.

The use of any single indicator has been shown to have a

low positive predictive value for true under nutrition.

A combination of anthropometric criteria, rather than one

criterion, should be used to more accurately identify

children at risk of FTT.

Weight for length is a better indicator of acute

undernutrition and is helpful in identifying children who

need prompt nutritional treatment.

Differences between WHO and CDC

infant charts

On the CDC chart, children appear heavier and shorter

On the WHO chart, children appear taller

WHO charts:

Higher estimate of overweight

Lower estimates of underweight, undernutrition

Prevalence

Although failure to thrive (FTT) is a common problem, precise

epidemiological data is lacking.

Depends mainly on the definition being used and the

demographics of the population being studied.

Approximately 80% of children with FTT present before 18

months of age.

FTT is seen in 5-10% of children in primary care settings and

in 3-5% of children in hospital settings.(USA), our data????

Range anywhere between 1.3% and 20.9% depending on the

definition of FTT that is used.

Etiology

Traditionally, the causes of FTT were subdivided into

organic (medical) and nonorganic (social or

environmental).

There is increasing recognition that in many children

the cause is multifactorial and includes biologic,

psychosocial, and environmental contributors.

Furthermore, in more than 80% of cases, a clear

underlying medical condition is never identified

(Stephens MB, Gentry BC, Michener MD, Kendall SK, Gauer R. Clinical inquiries. What is the clinical workup for failure to

thrive? J Fam Pract. 2008;57(4):264–266.)

Inadequate calorie intake

Incorrect prep of formula

Unsuitable feeding habits

Behavior problems affecting eating

Poverty and food shortage

Neglect, Disturbed parent-child relationship

Mechanical feeding difficulties (cleft palate, TEF)

Inadequate absorption

Celiac disease

Cystic fibrosis

Cow’s milk allergy

Vitamin or mineral deficiency

Biliary atresia or liver disease

Necrotizing enterocolitis or short gut

Increased metabolism

Hyperthyroidism

Chronic infection- HIV, other immune diseases

Hypoxemia: congenital heart defects and chronic lung disease

Defective utilization

Genetic abnormalities- trisomies 21, 18, 13

Congenital infections

Metabolic disorders- storage diseases, amino acid disorders

Non organic (psychosocial)

Inadequate diet because of poverty/food insufficiency,

errors in food preparation Poor parenting skills (lack of knowledge of sufficient

diet) Child/parent interaction problems (autonomy struggles,

coercive feeding, maternal depression) Food refusal Parental cognitive or mental health problems Child abuse or neglect Emotional deprivation

Expected Feeding and Voiding

Patterns

Diagnostic Evaluation

An accurate, detailed account of a child's eating habits, caloric

intake, and parent-child interactions should be obtained as a key

step in determining the etiology of FTT.

observing breastfeeding (proper technique, latch-on, and

swallow.

Alternatively, obtaining the weight of an undressed breastfed

infant on a high-quality infant scale before and after feeding .

For formula-fed infants, caregivers should demonstrate their

mixing technique during observation of a feeding.

Observing a toddler's eating habits can be helpful in evaluating

for picky eating or food refusal.

Diagnostic Evaluation ..continue Eating habits inside and outside of the home (e.g., day

care, school), as well as about the eating habits of parents

or siblings at the same age as the patient.

psychosocial history is essential for detecting maternal or

patient depression, or identifying concerns about the

caregiver's intellectual abilities or social circumstances.

Review of systems that elicits recurrent infections,

respiratory symptoms, or vomiting or diarrhea, heart…

In children without obvious organic symptoms elicited on

history, 90% were ultimately diagnosed with a

behavioral cause of FTT.

The absence of obvious nonorganic symptoms does not

completely exclude a nonorganic cause

Diagnosis

History, physical examination, Screening test (CBP, GUE). Bone age is often helpful . Other tests, such as for thyroid function,

gastroesophageal reflux and malabsorption, organic and amino acids, HIV and other infectious etiologies, or cystic fibrosis (sweat test), should be performed if indicated by the history or physical examination

Red Flag Signs and Symptoms Suggesting

Medical Causes of Failure to Thrive

Treatment

If a diagnosis of FTT is made and no medical conditions are

suggested on examination, appropriate guidance for catch-up

growth should be made.

Age-appropriate nutritional counseling should be provided to

parents.

For parents of breastfed infants, recommending breastfeeding

more often, ensuring lactation support, or discussing formula

supplementation until catch-up growth is achieved may be

helpful.

Parents of formula-fed infants may be instructed on how to

make energy-dense formula by concentrating the ratio of

formula to water during periods of catch-up growth

Treatment…continue

Toddlers should avoid excessive juice or milk consumption

because this can interfere with proper nutrition

If a disease or medical condition is identified on history,

physical examination, or additional testing, the correct approach

will vary depending on the condition.

Finally, although medications such as megestrol (Megace) or

cyproheptadine have been shown to help promote weight gain in

children with cancer-related cachexia, they have not been

studied in other causes of FTT.

Growth hormone therapy also has not been widely studied in

children and adolescents who are not growth hormone–deficient

and is not recommended for management of FTT.

Psychosocial FTT

Meal time 20-30 min Solid food should be offered before the liquid Environmental distraction should be minimized child should eat with others No force feed Intake of water and juice should be minimized High calorie should be required The rule of 3's is quite helpful—3 meals, 3 snacks, and 3 choices Weight gain in response to adequate caloric feedings usually establishes the diagnosis of psychosocial FTT.

Prognosis and Outcomes

There is consensus that severe, prolonged

malnutrition, which is common in developing

countries, can negatively affect a child's future

growth and cognitive development.

Low-birth-weight preterm infants who develop FTT

have also demonstrated long-term developmental

effects.

A history of FTT, however, was associated with short

stature, poor school performance, and poor work

habits.

Prognosis and Outcomes…continue

FTF in the 1st year is ominous sign 1/3 of psychosocial FTT are delayed

development, behavior . FTT have more than 8, 4,3folds greater risk of

mortality than the normal (in sever, moderate, mild respectively)

children with a history of FTT are at increased

risk of recurrent FTT, and their growth should be monitored closely.

Prevention

Appropriate nutritional counseling and anticipatory

guidance at each well-child visit may help prevent

some cases of FTT.

Prompt intervention and close follow-up needed to reverse FTT pattern and prevent associated problems.

Breast feeding……

Complementary feeding (time and type)