Pediatirc/ Failure to Thrive (FTT)

The term ‘failure to thrive’ is used to describe suboptimal, weight gain in infants and
toddlers (malnourished infants and young children who fail to meet expected standards of
growth).
• FTT is a common problem in pediatrics, affecting 5% to 10% of young children and
approximately 3% to 5% of children admitted to hospitals.
• FTT is more common in children living in poverty and foster care and aff ects 15% of
these group

OTHER DEFINITIONS

• weight that falls or remains below the 5th percentile for age.
• weight that decreases crossing two major percentile lines on the growth chart over
time, (i.e., from above the 75th percentile to below the 25th)
• weight that is less than 80% of the median weight for the height of the child



Repeated observations are therefore essential and are usually available from the child’s
personal child health record

In children with FTT, malnutrition initially res ults in:

• Wasting (deficiency in weight gain). then
• Stunting (deficiency in linear growth) generally occurs after months of malnutrition.
• Head circumference generally is spared except with chronic, severe malnutrition.
• Weight for height below the 5th perce ntile remains the single best growth chart
indicator of acute undernutrition
• Children with chronic malnutrition often have a normal weight for height because
both their weight and height are reduced.

Causes of FTT:

• Non organic ( psychosocial FTT).
• Organic FTT is marked by an underlying medical condition

Non organic or psychosocial FTT:

It is far more common than organic FTT.
Psychosocial FTT is most often due to poverty or poor child -parent interaction.

Causes of Non organic (psychosocial FT T):

• Lack of food ( poverty)
• Lack of knowledge, (poor feeding techniques ,improper formula preparation,
improper mealtime environment)
• Parental depression ,emotional deprivation, Child abuse or neglect .

Organic Causes of Failure to Thrive:

Any chronic disease may lead to FTT
• Gastrointestinal: GER, celiac disease, pyloric stenosis, cleft lip/ palate, lactose
intolerance, Hirschsprung's disease, milk protein intolerance, hepatitis, cirrhosis,
pancreatic insufficiency, biliary disease, inflammatory bowel d isease, malabsorption
• Renal: UTI, RTA, DI, RF
• Cardiopulmonary: Cardiac diseases leading to CHF, asthma, BPD, CF, anatomic
abnormalities of the upper airway,
• Endocrine: Hyperthyroidism, DM, adrenal insufficiency or excess, parathyroid
disorders, pituitary disorders,
• Neurologic: MR, CP, degenerative disorders, CNS tumors
• Infectious: Parasitic or bacterial infections of the gastrointestinal tract, TB, HIV disea se
• Metabolic: IEM
• Genetics, Congenital: Chromosomal abnormalities, congenital syndromes (fetal alcohol
syndrome), perinatal infections
• Miscellaneous :Lead poisoning, malignancy, collagen vascular disease, recurrently
infected adenoids and tonsils

DIAGNOSI S AND CLINICAL MANIFESTATIONS

History
• prenatal and postnatal factors :
That influence growth, including the history of prenatal care, maternal illnesses during
pregnancy, to
1. Identify fetal growth problems (IUGR), birth size (weight, length, and head
circumference).

2. Identify prematurity

3. Indicators of medical diseases (review of systems ):
such as vomiting, diarrhea, fever, respiratory symptoms, etc
• Careful dietary history is essential :
The adequacy of the maternal milk supply or the precise preparation of formula should be
evaluated.
For older infants and young children, a detailed diet history is helpful,
it is essential to evaluate intake of solid foods and liquids. Because of parental dietary
beliefs, some children have inappropriately restricted diets. Other children with FTT drink
excessive amounts of fruit juice, leading to malabsorption or anorexia for more nutrient -
dense foods..
• Social environment : poverty, unemployment, conflict , disruptive parent -child
interactions

Physical examination :

• Growth chart: weight, height, OFC
• Systemic examination:
• Physical findings related to malnutrition, such as dermatitis, pallor, or edema
• Additionally, severely malnourished children are at risk for a variety of
infections.
• Depending on severity, the infant with FTT may exhibit thin extremities, a narrow
face, prominent ribs, and wasted buttocks. Neglect of hygiene may be evidenced by
diaper rash, unwashed skin, untreated impetigo, uncut and dirty fingernails, or
unwashed clo thing. A flattened occiput with hair loss may indicate that the child has
been lying on his or her back. This flattening may be due to being unattended for
prolonged periods. Delays in social and speech development are common. Other
findings may include an avoidance of eye contact, an expressionless face, hypotonia,
and the absence of a cuddling response.

Laboratory evaluation:

There is no need for extensive laboratory search for medical diseases
Simple screening tests are recommended to screen for the common illnesses that may
cause growth failure and to search for medical problems that result from malnutrition.
Recommended laboratory tests include:

• CBP : type of anemia, WBC abnormalities (leucocytosis, lymphopenia)

• Urinalysis, urine culture: UTI
• Ser um electrolytes & RFT
• Serum protein: Degree of protein deficiency
• Blood sugar: hpoglycemia
• Stool sample for culture and ova and parasites may be indicated for children with
diarrhea, abdominal pain, or malodorous stools.
• PPD: screen for TB

TREATMENT

Most children with FTT can be treated in the outpatient setting .
Hospitalization is required for
• Children with severe malnutrition.
• Children with underlying diagnoses that require hospitalization for evaluation or
treatment.
• Children whose safety is in da nger because of maltreatment( social issues of the family).

Nutritional management :

• It is the cornerstone of treatment of FTT, regardless of the etiology.
• In general, the simplest and least costly approach to dietary change is warranted.

Amount:

• SLOW GRA DUAL INCREMENT
o Calories can be safely started at 20% above the child recent intake
o If no estimate of the caloric intake is available 50 -75% of,50 -75% of the normal
energy requirement is safe.
o Caloric intake can be increased 10 -20% per day. with monitoring for electrolyte
imbalances, poor cardiac function, edema, or feeding intolerance. If any of these
occurs, further caloric increases are not made until the child's status stabilizes.
• The final target is to provide 100 to 120 kcal/kg based on ideal weight.

Type:

according to age of the child & type of feeding :
✎ Breast fed infant: continue breast feeding and may add cow milk or special cows’
milk based formula (F75 or F100).
✎ Bottle fed :
Increased amount of cow milk ,or change to other types if indicated like:
• special cows’ milk based formula(F75 or F100)
• calorically dense formula (for anorectic and picky eater) concentration of
formula can be changed from 20 cal/oz to 24 or 27 cal/oz
• soy based (isomil) for lactose -into lerant child
• hydrolyzed protein type (pregestemil) for cow milk protein intolerant
• home made (oil,butter,peanut butter, others)
✎ Toddlers:
• Dietary changes should include increasing the caloric density of favorite foods
by adding butter, oil, peanut butter , or other high -calorie foods.
• High -calorie oral supplements that provide 30 cal/oz are often well tolerated
by toddlers.

Vitamin and mineral supplementation:

It is needed, especially during catch -up growth. Vitamin and mineral intake in excess of the
da ily recommended intake is provided to account for the increased requirements; this is
frequently accomplished by giving an age -appropriate daily multiple vitamin.