Approach to a baby who fails to thrive

Definition

  • Physical growth is significantly less than that of his/her peers
  • Usually refers to growth below the 3rd or 5th percentile or a change in growth that has crossed two major growth percentile(i.e., from above the 75th percentile to below the 25th )in a short time.

FTT Criteria

  • Height/Weight less than 3rd to 5th percentile for age on >1 occasion
  • Height or Weight falling 2 major percentiles
  • < 80% of ideal body Weight for age
  • Head circumference important, but not part of FTT entity

It occurs because of

  • Failure of the parent to offer an adequate amount of calories
  • Failure of the child to take sufficient amount of calories
  • Failure of the child to retain sufficient calories

Causes

  • It may be due to different organic diseases
  • Or it is caused by psychosocial (nonorganic) causes

A. Inorganic causes

Prenatal factors
  • Malnourished mothers
  • Teenage pregnancies
  • Unwanted pregnancies
  • Maternal eating disorders(eg, anorexia, bulimia)
  • multiple gestations
Postnatal factors
  • Poor feeding or feeding-skills disorder
  • Difficult parent-child interactions
  • Lack of support (eg, no friends, no extended family)
  • Lack of preparation for parenting
  • Family dysfunction (eg, divorce, spouse abuse, chaotic family style)
  • Child neglect
  • Emotional deprivation syndrome
  • Feeding disorders (eg, anorexia, bulimia)

B. Organic causes

Prenatal causes
  • Prematurity with complications
  • Toxic exposure in utero (Alcohol, smoking, medications, infections
  • Chromosomal abnormalities
Postnatal causes
Inadequate intake
  • Lack of appetite (eg, iron deficiency anemia, CNS pathology, chronic infection)
  • Inability to suck or swallow: cleft palate, Pierre Robin Syndrome, Neuromuscular incoordination, cerebral palsy, brain stem tumor
  • Vomiting (eg, CNS, metabolic, obstruction, renal)
  • Dysphagia eg. gastroesophageal reflux and esophagitis
Poor absorption and/or use of nutrients
  • GI disorder (eg, celiac disease, chronic diarrhea, protein-losing enteropathy, Short gut syndrome)
  • Renal: renal failure, renal tubular acidosis
  • Endocrine: hypothyroidism, diabetes mellitus, growth hormone deficiency
  • Inborn error of metabolism
  • Chronic infection (eg, HIV, tuberculosis, parasites)
Increased metabolic demand
  • Hyperthyroidism
  • Chronic disease (eg, heart failure, BPD)
  • Chronic inflammatory conditions (eg, inflammatory bowel disease,
    lupus erythematosus)
  • Renal failure
  • Malignancy

History

  • Age- help to determine the cause - perinatal infections, inborn errors of metabolism, cystic fibrosis
  • Sex- females are more vulnerable due to social factors
  • Occupation of the parents
  • Presenting complaints ranges simply from not gaining weight to global developmental delay or features of some organic diseases.
  • History to rule out organic causes
    1. - unable to swallow, diarrhea, vomiting, fatty stools, food refusals ( GI problems)
    2. - urine color, frequency, output, ( urinary problem)
    3. - breathing difficulties, fever, recurrent pneumonia (respiratory/cardiac problems)
    4. -Persistent fever, weight loss ( chronic infection)

Past Medical History
Events during pregnancy
  • weight gain during pregnancy
  • Gravida, Parity, Abortions
  • infectious diseases the mother had during pregnancy
  • whether she smoked cigarettes or used drugs or alcohol.
Birth and early neonatal history
  • Hospital/home delivery
  • Mode of delivery and complications, if any
  • APGAR scores
  • Gestational age
  • Small for gestational age
  • Perinatal infection to mother
  • Neonatal course & complications, including sepsis,jaundice, feeding intolerance, or feeding difficulties
History of breastfeeding
  • infrequent or brief feedings
  • nipple problems, inadequate milk secretion and poor sucking.
  • maternal ingestion of a milk suppressant (e.g., alcohol)
The feeding history
-Frequency of feeding
-An error in the preparation of formula or improper feeding technique.
-Timing of weaning
-Quality and the quantity of the food
-Food refusal by the child
Immunization history 

History of developmental milestones 

Psychosocial history
  • marital stress, divorce
  • Unemployment and financial difficulties,
  • parental absences,
  • social isolation and substance abuse,
  • degree of interest and concern the parents have for the child, amount of time they spend
  • Whether the child was planned or "wanted"
Family history
-Similar problem in siblings
-History of consanguinity
-Weight and height of the child's parents, grandparents - give clues about the presence of genetic, chromosomal or metabolic disorders.
-Education level of parents
-Contact history with tuberculosis
-Mental illness in the family

Physical examination

  • General appearance -dull vacant stare
  • poor hygiene
  • passive or irritable infant
  • Vital signs are important
    • Blood pressure
    • Pulse rate
    • Temperature
    • Respiration rate
    • Oxygen saturation
  • Anthropometric measurements (all below 3rd percentiles or cross 2 growth percentiles)
Weight
height
head circumference
  • Developmental assessments
    • Delay in the development of gross motor function as a result of neuromuscular weakness.
    • Expressive language development and social skills - may be delayed in children with nonorganic failure to thrive
  • failure to thrive in infancy is associated with adverse intellectual outcomes sufficiently large to be of importance at a population level. (J Child Psychol Psychiatry. 2004 Mar;45(3):641-54)
  • Undress the baby and head to toe examination
-Skin rashes and hair changes, pallor, signs of vitamin deficiencies
-Head -small and abnormal shape, dysmorphic face, cleft palate, cleft lip, low set ear, protruding tongue
-Chest-abnormal shape, abnormal Breath sounds, Cardiac examination for murmurs or cardiomegaly or arrhythmias
-Protruding abdomen, organomegaly masses
-Wasted buttocks
-Thin limbs or edematous

Laboratory work up

  • complete blood count (screens for anemia or low blood counts),
  • erythrocyte sedimentation rate(which can be elevated with inflammation or infections),
  • urinalysis and urine culture (can show evidence of a renal tubular acidosis or chronic renal disease or infections),
  • blood chemistry tests (renal function tests, liver function tests, mineral levels (calcium, magnesium, lead),
  • stool tests for fat, culture, and parasites,
  • sweat chloride test (for cystic fibrosis),
  • HIV test,
  • Mantoux test (for tuberculosis)
  • serum glucose to look for diabetes,
  • thyroid function tests,
  • blood and urine tests to look for metabolic problems, and
  • upper or lower gastrointestinal endoscopy for persistent vomiting and/or chronic diarrhea
  • Radiological studies as indicated chest X-ray, other x-rays to see bone age, occult trauma due to child abuse, CT scanning head to look for micro/macrocephaly, brain atrophy, congenital malformations
  • Metabolic and endocrinological screenings

Management

  • Identification of the underlying cause & its correction
  • Nutrition intervention or feeding behavior modification
  • High-calorie diet for catch up growth
  • Education to Parents or caregiver
Recommendations for Energy Intake
AgeEnergy (kcal per kg per day) guidelines for average replacement
10 days to one month120
One to two months115
Two to three months105
Three to six months95
Six months to five years90
Adapted with permission from Hay WW.

Current pediatric diagnosis and treatment. 15th ed. Norwalk, Conn.: Appleton & Lange, 2001:250.
  • Close follow up with growth monitoring
  • If a cause is not apparent after a thorough history, physical examination & preliminary lab. evaluation then hospitalization may help identify inadequate calorie intake or psychosocial problems.
Indications for hospitalization
  • weight below birth weight at 6 Wks
  • very young infant
  • failure of out-patient therapy
  • work-up needed for organic causes
  • unsafe home
Summary: G.R.O.W.T.H.
  • Gather history and extensive physical examination
  • Remember genetic contribution
  • Only order basic labs in the initial evaluation
  • Wonder about zebras
  • Track growth trends
  • Hospitalize if required

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