Pediatrics Failure to Thrive Overview

Failure to Thrive - Clinical Findings

• Failure to thrive (FTT) diagnosis requires a comprehensive, long-term growth curve.
• In acute undernutrition, weight gain slows, but height velocity remains stable. This leads to a thin child of normal height.
• Chronic undernutrition results in stunting, affecting both height and weight.
• Growth charts show that healthy children can cross percentile lines up to 39% of the time between birth and 6 months of age and 15% of the time between 6 and 24 months. Children with length above the 50th percentile rarely have endocrine disease.

History

• A detailed medical history and physical examination are vital for identifying organ dysfunction, potential causes of growth failure (poor suck, cleft palate, etc.).
• Recurrent infections, immune deficiencies (HIV), and cardiac problems warrant investigation.
• Chronic conditions, like diarrhea, indicate malabsorption and require attention.
• Developmental history, a history of intercurrent illnesses and delay in reaching milestones are also important for diagnosis.
• History of specific prenatal exposures (infections, drug exposure) and low birth weight increase the risk of growth problems.
• Infants exposed to conditions like rubella, cytomegalovirus, syphilis, toxoplasmosis, or malaria in utero are at higher risk for low birth weight, length, and head circumference. These features predict poor catch-up growth potential.
• Feeding history is crucial. Volume and frequency of feedings, formula preparation, and feeding issues (poor suck, regurgitation, bottle propping) are key.
• Breastfeeding mothers must be educated before discharge about expectations.
• Neonates should typically feed at least 8 times per 24 hours and not sleep through the night.
• 24-hour/72-hour diet recall is essential for accurate assessment of dietary intake in older children.

Physical Examination

• Physical examination complements growth charts. Weight, length/height, and head circumference should be assessed in all children.
• Objective findings of nutritional state including decreased subcutaneous fat and muscle wasting.
• Careful assessment of nail beds and hair, and skin for scaling/cracking (indicators of deficiencies).
• Presence of eczema points towards allergic diathesis or eosinophilic enteritis, a potential problem in undernourished children.
• Abdominal examination important to screen for organomegaly, which can indicate an underlying metabolic condition.
• Neurological assessment can detect subtly increased or decreased muscle tone, consistent with cerebral palsy or difficulties with oral motor skills.

Laboratory Findings

• Laboratory evaluation may be crucial if clinical examination shows abnormalities not reflected in diet history.
• Tests for organ issues, genetic disorders and inborn errors of metabolism are important.
• Serum albumin, though not a reliable indicator of recent undernutrition, is a marker of nutritional status. Prealbumin is a better marker of recent protein nutrition.
• Reduced lymphocyte count could suggest malnutrition. Assessment of iron levels important. Elevated lead levels warrant investigation given lead exposure potential affecting absorption of iron.
• Evaluate for infectious diseases (like TB, HIV), and conditions such as celiac disease, particularly when solid foods have been introduced.

Differential Diagnosis

• Family history is essential for differentiating constitutional growth delay from FTT.
• The calculation of midparental height is helpful in differentiating growth-related problems from genetic predisposition.

Treatment

• Nutritional support is the cornerstone of treatment.
• Children with FTT might require 1.5-2 times the usual daily caloric intake to achieve catch-up growth.
• Increased protein intake may be needed in severe malnutrition.
• High-calorie formulas and foods, heavy cream, and other high-calorie additions to regular diets may be necessary.
• Dietary management should require input from a dietitian.
• Some medications such as iron and zinc supplementation, and vitamin D replacement might be considered as necessary nutritional support.