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Title: Failure to Thrive: An Update

Type of Paper: Featured Article

Purpose: To describe the definition, cause, diagnosis and treatment of failure to thrive in infants and children.

Definition: Typically a term used to describe inadequate growth or the inability to maintain growth, failure to thrive (FTT) is ultimately a sign of undernutrition. In clinical practice, FTT is typically defined as either weight-for-age below the 5th percentile on multiple occasions or weight loss that crosses two major percentile lines on a growth chart. It is recommended that multiple anthropometric criteria be used to accurately identify children with FTT. The World Health Organizations recommends using weight velocities in which weight change over a 1-2 month period is compared with population data. Using weight velocities accounts for age-dependent changes in growth while simultaneously allowing for a rapid assessment of poor weight gain. The use of weight and height velocities in identifying children at risk for FTT also account for children who fall behind in other growth parameters, such as children of small-statured parents, large-for-gestational age infants, children with growth delays or premature infants.

Cause: Causes of FTT are best categorized by calories: inadequate caloric intake, inadequate caloric absorption or excessive caloric expenditure. In infants, inadequate caloric intake can be caused by a breastfeeding problem, improper formula preparation, gastric reflux, caregiver depression, lack of food availability, or cleft lip/palate. In children, inadequate caloric intake can be caused by mood or eating disorders, gastric reflux or irritable bowel syndrome. In infants and children, inadequate caloric absorption can be caused by food allergies, malabsorption, gastrointestinal malformations, celiac disease, inflammatory bowel disease or metabolism errors. In infants and children, excessive caloric expenditure can be caused by thyroid disease, immunodeficiency, chronic infection, chronic pulmonary disease, congenital heart disease or malignancy.

Diagnosis: Diagnosis of FTT requires multiple evaluations, including medical, psychosocial and dietary histories, physical examination, and laboratory testing. A review of children’s health and illness history, including recurrent infections, respiratory symptoms, vomiting and diarrhea, may point health care professionals to a non-behavioral cause of FTT. For infants, intake of breast milk or formula should be documented. Caregivers should be observed for breast and bottle-feeding techniques, as well as formula mixing techniques. A food journal can be kept to document the eating habits of young children. Psychosocial history is critical to detecting caregiver depression or intellectual abilities. Physical exams should include anthropometrics and a normal scan for signs of abuse or neglect. Laboratory testing for conditions such as HIV, tuberculosis and immunoglobin levels, helps identify FTT in less than 1 percent of children.

Treatment: Typically, nutritional supplements and calorie-dense foods are recommended so an infant or child may achieve catch-up growth. Catch-up growth should be carefully monitored by a health care professional. Multidisciplinary interventions, including nutritional counseling, should be considered to improve weight gain, caregiver-child relationships and cognitive development. In severe cases, hospitalization should be considered if a child does not improve, if there is suspicion of abuse or neglect, if caregiver psychosocial impairment is present, or there are signs of serious malnutrition.

Implications: FTT that is a result of the severe malnutrition commonly seen in developing countries can negatively affect a child’s growth potential and cognitive development. The earlier FTT is diagnosed and treated in infants and young children, the better the cognitive development outcomes. Children with FTT are at an increased risk of recurring FTT.

Citation/Reference: Cole, S.Z., & Lanham, J.S. Failure to Thrive: An Update. American Family Physician. April 1, 2011; 83(7): 829-834. http://www.ncbi.nlm.nih.gov/pubmed/21524049


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