Failure to Thrive

Susan Schayes M.D.

Emory Family Medicine
Emory SOM

6/11/2014 Failure to Thrive Acknowledge
Shannon Pittmann
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In the State of Georgia, an adult is required to pass both a
written and a road test to get a drivers license. No such
requirement exists for parenting.
Objectives
To define failure to thrive (FTT)
To identify major classification of FTT
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To discuss diagnostic workup of FTT
To discuss treatment of FTT

Failure to Thrive
A descriptive term, not a specific diagnosis








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Diagnoses when a childs weight for age is
below the fifth percentile or crosses two
major percentile lines
The key is to accurately measure wt, ht at
each visit.

Failure to Thrive
A sign the describes a particular problem

Requires us to STOP
and THINK.







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Failure to Thrive
Best defined as inadequate physical growth






,

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Diagnosed by observation of growth over
time using standard growth charts.
Preferred growth charts are from the
National Center for Health Statistics
(NCHS) found at www.cdc.gov

FTT Criteria
Ht/Wgt less than 3
rd
to 5
th

percentile for age on >1 occasion
Ht or Wgt falling 2 major percentiles
Below 10
th
percentile for ht/wgt
< 80% of ideal body wgt for age
Head circumference important, but
not part of FTT entity
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OK135S053
OK135S054
OK135S055
OK135S056
Selective Differential Dx
Inadequate caloric intake
Inadequate absorption
Increased metabolism
Defective utilization

6/11/2014 Failure to Thrive, Am Fam
Physician 2003;68:879-84
12
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FTT Definition
Inadequate physical growth diagnosed
by observation of growth over time
using a standard growth chart

DO HT, WT and observe trends
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Were not alone
In England, 54% of GPs failed to
diagnosis FTT
Residency clinic, 41% with delayed Dx
Residency clinic, 29 Dx, 100% Dx
incorrectly

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1. Batchelor JA. Has recognition of
failure to thrive changed?
Child Care Health Dev 1996;22:235-40
2.Krugman et al. Missed
opportunities to diagnose
failure to thrive in a family
medicine resident practice.
Pediatr Res 2000:47
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FTT
HISTORY ! HISTORY! HISTORY!
Prenatal
Feeding
# oz needed in 24 hours
Wgt (kgs) x 5
(need 100 kcal/kg/day, formula 20kcal/oz)
How formula prepared
Good diet history (3 day journal)
Bowel habits
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Normal Growth
Average wgt 7 lbs (3kg)
Double by 4 months, triple by 12
Grow 25 cm in length during 1
st
year
Make sure you have the right chart
Premature
Breastfeeding
Ethnic
Down Syndrome
www.cdc.gov/growthcharts

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Normal Growth
Newborns can lose 10% of weight in
first few days, gain back by 2 weeks
Infants gain 1 kg/month 0-3 months
gain .5 kg/month 3-6 months
gain .33kg/month 6-9 months


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Bassali et al, Failure to Thrive
www.emedicine,com/PED/topic7
38.htm, updated April 25, 2006
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Normal Growth






6/11/2014
Bassali et al, Failure to Thrive
www.emedicine,com/PED/topic7
38.htm, updated April 25, 2006
20
AGE Median Daily Weight Gain
Grams
0-3 months 26-31 grams
3-6 months 17-18 grams

6-9 months 12-13 grams
9-12 months 9 grams
1-3 years 7-9 grams
4-6 years 6 grams
Organic causes of FTT






6/11/2014
Bassali et al, Failure to Thrive
www.emedicine,com/PED/topic7
38.htm, updated April 25, 2006
21
Prenatal Causes Post natal causes
Prematurity Inadequate intake
Maternal malnutrition Poor absorption & or use

Toxic exposure in utero Increased metabolic
demand
Alcohol, smoking, meds Inadequate absorption
Infections
IUGR
Abnormal chromosomes
Incorrect prep of formula
Unsuitable feeding habits
Behavior problems affecting eating
Poverty and food shortage
Neglect, Disturbed parent-child
relationship
Mechanical feeding difficulties


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Inadequate calorie intake
Celiac disease
Cystic fibrosis
Cows milk allergy
Poverty and food shortage
Vitamin or mineral deficiency
Biliary atresia or liver disease
Necrotizing enterocolitis or short
gut


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Inadequate absorption
Hyperthyroidism
Chronic infection- HIV, other immune
diseases
Hypoxemia-congenital heart defects
and chronic lung disease




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Increased metabolism
Genetic abnormalities- trisomies 21,
18, 13
Congenital infections
Metabolic disorders- storage
diseases, amino acid disorders



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Defective utilization
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Introduction to IEM
Usually a single gene defect that
causes a block in metabolic pathways.

Problems are because of
accumulation of enzyme substrate
behind the metabolic block or
deficiency of the reaction product.
IEM


In some instances the substrate is
diffusible & affects distant organs &
in some there is just a local effect (
lysosomal storage disease ).
IEM Associations
Odors :-
Glutaric acidemia type 2 sweaty feet
Isovaleric acidemia sweaty feet
Hawkinsuria swimming pool
MSUD maple syrup
Methionine malabsorption cabbage
Multiple carboxylase deficiency tomcat urine
Oasthouse urine disease hops like
PKU mousy or musty
Trimethlyaminuria rotting fish
Tyrosinemia rancid fishy or cabbage like
FTT
Physical
Gomez Criteria- comparing the current
expected weight for age 50 percentile
<60% = severe; 61-75% = mod; 76-90% =
mild
Kwashiorkor protein malnourishment
Marasmus caloric deficiency
Short Stature Syndrome
Constitutional Delay

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FTT - Classification
Organic FTT
Pre/postnatal
Nonorganic FTT (NOFT)
Pre/postnatal
Mixed (25%)

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FTT - Classification
Nonorganic
Prenatal
Malnourished mother
? Lack of prenatal bonding
Postnatal
Poor feeding skills/disorder
Dysfunctional family
Difficult parent-child interactions
Difficult Child
Abuse/Neglect

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FTT - Classification
Organic, postnatal cont.
Poor absorption and/or use of nutrients
GI disorder (celiac, CF)
Inborn errors of metabolism
Increased metabolic demand
Hyperthyroidism
Chronic Disease

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FTT - Classification
Organic FTT
Prenatal Causes
Prematurity w/complications
Toxic exposure
Postnatal
Inadequate intake
Lack of appetite
Inability to suck/swallow

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Recap - Classification
Failure to Thrive
Organic
Nonorganic
Prenatal Postnatal
Toxic Exposure Inborn errors
Prenatal Postnatal
Malnourished
mother
Abuse/Neglect
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FTT - Workup
+/- Basic screening labs
CBC, Chemistry, & UA
Specific test directed by history
HIV, ESR, TSH, Sweat chloride test,
serum IGF-I, serum IgA/IgG antigliadin
antibiodies
X-rays for bone age

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FTT Treatment
High calorie diet for catch up growth
150% of recommended daily caloric intake
based on expected wgt
+/- Feeding behavior modification
Psychosocial involvement/ intervention
Close follow up
Physical and cognitive delays
Hospitalization when necessary
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Summary: G.R.O.W.T.H.
Gather history and extensive physical
Remember genetic contribution
Only order basic labs in initial eval
Wonder about zebras
Track growth trends
Hospitalize or hormonally treat
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Why Do We Have to Talk
About it at All?
Personal
Depending on current status in app. 7, 19, or 31 months
you will sit for the ABFM (13%-pediatrics)
ACGME competencies / AAFP core recommendations

Patients
Parental concerns
Doc, is my baby growing right?
Cognitive development
Arch Dis Child. 2005 Sep;90(9):925-31. Epub 2005 May 12.
J Child Psychol Psychiatry. 2004 Mar;45(3):641-54.




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Take Home
The keys to diagnosing FTT is finding the
time to accurately measure and plot
wgt/ht and then access the trend
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References
Listernick, R. (2004). Accurate feeding history key to
failure to thrive. Pediatr Ann, 33:3, 161-9.
Burgos, R., Jutte, D. (2000). Residents column: doctor, is
my child growing ok?. Pediatr Ann, 29:9, 585-7.
Krugman, S., Dubowitz,H. (2003). Failure to thrive.
American Fam Phy, 68:5, 879-84.
Schwartz, R., Abegglen, J. (1996). Failure to thrive: an
ambulatory approach. Nurse Pract, 21:5, 19-31.
Careaga, M., Kernder, J. (200). A gastroenterologists
approach to failure to thrive. Pediatr Ann. 29:9, 558-67.
Bassali, R., Benjamin, J. (2004, August 11). Failure to Thrive.
eMedicine. Retrieved September 17, 2005, from
http:///www.emedicine.com/ped/topic738.htm.



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