Seminar on:

Failure to thrive
GROUP – 5

BDU, CMHS
C-1
01/01/ 2008 E.C
05/01/2008 E.C 1
Contents
Definition
Overview of Normal growth patterns
Epidemiology
Classification of FTT
Risk factors
Etiologies
Approach a child with FTT
Clinical manifestations
Assessment of FTT
Work UP
Severe Acute Malnutrition

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Definition

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Definition
Failure to thrive (FTT) is a descriptive term
applied when a young child’s physical growth
is less than that of his or her peers
failure to attain the potentials expected for a
child of that specific age and sex
Sign of unexplained Wt lose or poor Wt gain
linear growth and head circumference also
may be affected

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 Cont’d...
common terms to describe FTT;
Failure to gain weight
Failure to grow
Growth deficiency
Growth faltering
Undernutrition

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 Cont’d...
Greatest Growth velocity of A Child
occurs at ;
First 2 years of life &
Earliest teens
It is at these times that the children most
probably fail to thrive.

05/01/2008 E.C 6
 Cont’d...

The term FTT is not a disease

The best definition for FTT is the one that refers
to it as inadequate physical growth diagnosed
by observation of growth over time using a
standard growth chart

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 The most common definition is weight less than
the 3rd or 5th percentile for age on more than
one occasion, or
weight measurements that fall 2 major
percentile lines using the standard growth
charts of the National Center for Health
Statistics (NCHS)
(MEDscape)

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 Overview of Normal Growth patterns
Introduction
Normal growth is the progression of
changes in height, weight, and head
circumference that are compatible with
established standards for a given population

The progression of growth is

interpreted within the context of the
genetic potential for a particular child.

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 Term infants: Lose 5-10% of birth Wt, regain by
10-14 days
Infant Wt gain pattern:
1kg/mo for the first 3 months
0.5kg/mo from age 3-6 months
0.33kg/mo from age 6-9 months
0.25kg/mo from age 9-12 months
Double the birth Wt by 4-6 mo
Triple the birth Wt by 1yr of age

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 Cont....d
Normal growth is a reflection of overall health
and nutritional status.
Understanding the normal patterns of growth
enables
Early detection of pathologic deviations (eg, poor
weight gain due to a metabolic disorder, short
stature due to inflammatory bowel disease) and
Prevent the unnecessary evaluation of children
with acceptable normal variations in growth

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 Growth velocity
The change in growth over time,
A more sensitive index of growth than is a
single measurement.
Current growth points should be compared to
previous growth points, if possible, to determine
the interval growth velocity

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 Height velocity
Average normal length or height velocities are
as follows
0 to 6 months –--- (2.5 cm) per month
7 to 12 months – (1.25 cm) per month
12 to 24 months – (10 cm) per year
24 to 36 months – (8 cm) per year
36 to 48 months – (7 cm) per year
4 to 10 years ------- (5 to 6 cm) per year

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 Head Growth
Head circumference:
Average at birth is 35cm
47cm by 1yr of age, rate then slows
Average of 55cm by 6 yrs of age

 Brain weight doubles by four to 6 months of age and

triples by one year of age
 The majority of head growth is complete by 4 years of
age

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 Cont’d...
 Corrections for gestational age should be made for
premature infant
– for weight through 24 months of age,
– for stature through 40 months of age, and
– for head circumference through 18 months of age
 Special growth charts exist for some genetic disorders,
such as Down syndrome

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 Exception to the definition
Children with genetically short stature, SGA
infants, and preterm infants
preterm infants: plot using corrected age
until 2yrs of age if birth Wt > 1000gm
until 3yrs of age if birth Wt < 1000gm
Catch-up growth for premature infants:
18mo for HC
24mo for Wt
40mo for Ht
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Epidemiology

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 EPIDEMIOLOGY
True incidence of FTT is not known
In developed nations
5–10% of young children
3–5% of children admitted into teaching hospitals
Prevalence higher in developing countries , why?
Poverty
malnutrition
HIV infection

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 Cont’d...

Under-feeding is the single commonest cause

of FTT
95% of cases of FTT inadequate food
peak incidence of FTT the age of 9–24 mo
No significant gender difference
Majority of children ≤18 months old
Uncommon after the age of 5 years

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Risk Factors

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 Medical risk factors for FTT include;
prematurity
Intrauterine growth restriction(IUGR)
Developmental delay
Congenital anomalies (e.g., cleft lip and/or palate),
Intrauterine exposures (e.g., alcohol, anticonvulsants,
infection, lead poisoning, anemia) and
Any medical condition that results in inadequate
intake, increased metabolic rate, maldigestion, or
malabsorption

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 Psychosocial risk factors for FTT include:
Poverty
Certain health and nutrition beliefs (e.g., fear of obesity
or cardiovascular disease, prolonged exclusive breastfeeding),
Social isolation
Life stresses
Poor parenting skills
Disordered feeding techniques
Drug or substance abuse
Other psychopathology
violence, and abuse
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Classification

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 Classification
Traditionally, classified as
1.Organic FTT
2○ to underlining medical illnesses
Account for less than 20% of cases
2.Nonorganic FTT (NOFT)
Psychosocial FTT
No known medical condition that causes poor
growth
Inadequate food or undernutrition
Accounts for over 70% of cases

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 3 . Mixed FTT
Organic and non organic causes coexist.
Those with organic disorders may also suffer
from environmental deprivation
Likewise, those with severe undernutrition
From non-organic FTT can develop organic
medical problems

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 Cont’d...
Based on pathophysiology, FTT may be classified
into those due to:
1. inadequate caloric intake
2. inadequate absorption
3. increased caloric requirement, and
4. defective utilization of calories
This classification leads to a logical organization of many
conditions that cause or contribute to FTT; which is the
preferred classification,
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Etiologies of FTT

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 Etiologies
Etiologies of FTT by pathophysiology
1. Inadequate caloric intake
Inappropriate feeding technique
Inappropriate nutrient intake :
excess fruit juice consumption
inappropriate preparation of formula
inadequate quantity of food,
inappropriate food for age,
neglect
Inappropriate parental knowledge
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 Disturbed caregiver/child relationship
Economic deprivation
Insufficient lactation in mother
Mechanical problems (cleft palate, nasal
obstruction, adenoidal hypertrophy, dental
lesions)
Sucking or swallowing dysfunction (CNS,
neuromuscular)

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 2. Inadequate Absorption or Increased Losses
Malabsorption
lactose intolerance
cystic fibrosis
cardiac disease
malrotation
inflammatory bowel disease(IBD)
milk allergy
parasites
celiac disease

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 Biliary atresia
Cirrhosis
Vomiting
Infectious gastroenteritis
Increased intracranial pressure
Intestinal tract obstruction (pyloric stenosis,
hernia, malrotation, intussusception)
Infectious diarrhoea
Necrotizing enterocolitis or short bowel
syndrome

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 3. Increased Caloric Requirement
Hyperthyroidism
Malignancy
Chronic inflammatory bowel disease
Chronic systemic disease (juvenile idiopathic
arthritis)
systemic infection
Urinary tract infection
Tuberculosis
Toxoplasmosis

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 Chronic metabolic problems
Hypercalcemia
Storage diseases
Inborn errors of metabolism
galactosemia
diabetes mellitus
adrenal insufficiency
Chronic respiratory insufficiency
bronchopulmonary dysplasia
cystic fibrosis
Congenital or acquired heart disease

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 Organic Causes Of FTT
CARDIAC PULMONARY/RESPIRATORY
Cyanotic heart Severe asthma
lesions Cystic fibrosis
Congestive heart Cronchiectasis
failure Chronic respiratory failure
Vascular rings Bronchopulmonary dysplasia
Adenoid/ tonsillar hypertrophy
Obstructive sleep apnea

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 GASTROINTESTINAL
Pyloric stenosis Milk intolerance: lactose,
Gastroesophageal reflux protein
Malrotation Pancreatic insufficiency
Malabsorption syndromes syndromes (cystic fibrosis)
Celiac disease Chronic cholestasis
Food allergy Inflammatory bowel
disease
Chronic congenital
diarrhea states
Short bowel syndrome
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 …
NEUROLOGIC
Cerebral palsy
Hypothalamic and other CNS tumors
Neuromuscular disorders
Neurodegenerative disorders
RENAL
Urinary tract infection
Renal tubular acidosis
Renal failure

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 …
ENDOCRINE
Diabetes mellitus
Diabetes insipidus
Hypothyroidism/hyperthyroidism
Growth hormone deficiency
Adrenal insufficiency

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 GENETIC/METABOLIC/CONGENITAL
Sickle cell disease
Inborn errors of metabolism (organic acidosis,
hyper- ammonemia, storage disease)
Fetal alcohol syndrome
Skeletal dysplasia
Chromosomal disorders
Multiple congenital anomaly syndromes (VATER,
CHARGE)
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 MISCELLANEOUS INFECTIONS
Collagen-vascular Perinatal infection
disease (TORCH)
Malignancy Occult/chronic
Primary infections
immunodeficiency Parasitic infestation
Transplantation Tuberculosis
HIV

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Non-organic FTT (Psychosocial/Behavioral)
Commonest Cause
Inadequate diet because of poverty/food
insufficiency
Errors in food preparation
Child/parent interaction problem
Poor parenting skill (lack of knowledge of
sufficient diet/feeding techniques)
Food refusal
Parental mental health/cognitive problems
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 ….
Child abuse/neglect
Family dysfunction: marital stress, mental
illness, substance abuse, …
Infant co-morbidities
Unintentional
Emotional deprivation

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APPROACH TO A CHILD WITH
FAILURE TO THRIVE
1. History Taking
Prenatal History
Smocking
Alcohol consuming
Use of medication
Any illness during pregnancy
 History
Postnatal History
Neonatal asphyxia/Apgar scores
Prematurity
Small for gestational age
Birth weight and length
Congenital malformations or infections
Maternal bonding at birth
Length of hospitalization
Feeding difficulties during neonatal period
 History
Feeding history
Details breast and formula feeding
Typical feeding schedule, plus food preparation
(formula prep, portion size)
Methods of feeding, length of time spent feeding,
and diet supplementation/medication
Description of type of solid foods taken
(quantitative composition and frequency of meals
and snacks)
Prospective 3-day food diary
 History
A direct observation- issues of sucking ability,
choking, regurgitation, vomiting, and diarrhea,
mother’s affect and attitude.

Change in formula, change from breast milk to

formula, and changes in the primary individuals
responsible for feeding the child

Parents’ attitude about feeding (restrictions of

food based on finances, religion
History
History
 History
Family History
stature and growth patterns
Medical problems
Genetic diseases
Developmental delays
 History
Age and occupation of parents
Who feeds the child?
Life stressors (loss of job, divorce, death in
family)
Availability of social and economic support
Perception of growth failure as a problem
History of violence or abuse of care-giver
Psychosocial History
Family composition
Any major events in the child’s life
Family stressors
Chronic Illness,
Martial stress
Single parenthood
Depression
Domestic violence
Substance abuse,
Employment / financial obligations
 History
Growth and eating pattern of other siblings
Young parental age
Affluent circumstances or parents engaged in career
development
Child rearing beliefs
 History
Poverty,
Certain health and nutrition beliefs (eg, fear of
obesity or cardiovascular disease, prolonged
exclusive breastfeeding),
Social isolation, life stresses,
Poor parenting skills,
Disordered feeding techniques,
Substance abuse or other psychopathology,
violence, and abuse
2. Physical Examination
The four main goals of physical examination
include
1. Identification of dysmorphic features
suggestive of a genetic disorder that affects
growth
2. Detection of an underlying disease that may
impair growth
3. Assessment for signs of possible child abuse
4. Assessment of the severity and possible effects
of malnutrition
 Physical examination
General appearance
Cachexia, temporal wasting, sparse hair or
alopecia  malnutrition
Dysmorphic features

Small palpebral fissures

Midface hypoplasia
Flat philtrum
Thin vermilion border of fetal alchohol syndrome)
 Physical examination
Vital signs
Temperature  hypothermia
PR  tachycardia
RR  tachypenic
BP  hypotension
Anthropometry derangements
 Physical examination
HEENT
Microcephaly
Delayed closure of fontanelle
Cataracts
Papilledema
Oropharyngeal lesions (eg, caries, tongue
enlargement, mandibular hypoplasia, tonsillar
hypertrophy, defects in soft or hard palate)
Delayed tooth eruption
Thyroid enlargement Thyroid disease
 Physical examination
Chest
Wheezing
Crackles
Prolonged expiratory phase
Hyperexpansion

Abdomen
Abdominal distension
hyperactive bowel sounds
Hepatosplenomegaly
 Physical examination
Genitourinary
Genitourinary abnormality
Rectal fistulae

Musculoskeletal
Bony deformities
Craniotabes
Beading of the ribs
Scoliosis
Bowing of the legs or distal radius and ulna
Enlargement of the wrist
Edema
 Physical examination
Skin and Mucous Membranes
Pallor
Clubbing
Scaling skin
Spoon-shaped nails
Iron deficiency
Cheilosis
Vitamin deficiency
Chronic diaper rash
 Physical examination
Neurologic
Abnormal deep tendon reflexes
Hypotonia
Weakness
Spasticity
Neuropathy
 Red Flag Signs and Symptoms Suggesting
Medical Causes of Failure to Thrive
• Cardiac findings suggesting congenital heart disease
or heart failure (e.g., murmur, edema, jugular venous
distention)
• Developmental delay
• Dysmorphic features
• Failure to gain weight despite adequate caloric intake
• Organomegaly or lymphadenopathy
• Recurrent or severe respiratory, mucocutaneous, or urinary
• Infection
• Recurrent vomiting, diarrhea, or dehydration

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Clinical Features
Most common clinical presentation is poor
growth
Accompanied by physical signs;
Alopecia
Reduced subcutaneous fat or muscles
Dermatitis
Syndromes of marasmus or kwashiorkor
Failure to meet expected age norms for ht and
wt
Recurrent infections
Depending on the severity infants with FTT
may exhibit
Thin extremities
Narrow face
Prominent ribs and wasted buttocks
 Cont’d…
Neglect of hygiene
Diaper rash
Unwashed skin
Uncut and dirty finger nails or
unwashed clothing
Delays in social and speech development
Expressionless face and hypotonic
 Assessment of FTT

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Anthropometric criteria:
1. A child younger than 2 years of age whose weight is
less than the 3rd or 5th percentile for age on > 1
occasion
2. A child younger than 2 years of age with weight is
less than 80% of the ideal weight for age
3. A child younger than 2 years whose weight for age
percentile crosses two major percentiles lines on a
standard weight curves below a previously
established growth rate
 ,,,,

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 Growth Charts

• Standard growth charts are commonly used to

define how the growth of a child compares to
normal.

• Growth charts are constructed using a group of

normal children living:
–In a given area at a given time.

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 Recommended growth charts
WHO growth charts :
For both boys and girls
• Weight-for-age
• Length-for-age
• Head circumference-for-age, and
• Weight-for-length
CDC/NCHS growth charts :
For both boys and girls
• Weight-for-age
• Length-for-age
• Head circumference-for-age, and
• Weight-for-length
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 Work Up

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 LABORATORY EVALUATION
Laboratory evaluation for organic disease should be
guided by the signs and symptoms found in the initial
evaluation.
A careful history and physical examination in the child
with failure to thrive (FTT) may suggest clues to an
organic disease
Laboratory studies that are not suggested on the basis
of the initial history and examination rarely are helpful.
One study revealed that only 1.4 % of the laboratory
studies performed in evaluating children with FTT were
useful diagnostically

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 Simple routine tests includes:
Random Blood Sugar(RBS)
complete blood count(CBC)
Urinalysis(U/A)
electrolyte levels
stool exam
PIHCT
TB

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 Severe Acute Malnutrition
 Severe acute malnutrition is defined by a very low weight for height
(below -3z scores of the median WHO growth standards), by
visible severe wasting, or by the presence of nutritional oedema

one of the most common causes of morbidity and mortality

among children under the age of 5 years WW

Child with edematous malnutrition Child with visible severe wasting

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 – Dx is made based on:
1. In infants < 6 months
 WFH < 70%(Severe wasting) of NCHS median, OR
 Bilateral pitting oedema of nutritional origin, OR
 Visible Severe Wasting if it is difficult to determine W/L
2. children 6 months up to 5 years
 WFH < 70%(Severe wasting) of NCHS median, OR
 Bilateral pitting oedema of nutritional origin, OR
 MUAC <11cm (for infants above 6months or >65cm length)

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Investigation: Blood culture
RBS-------Hypoglcemia sepsis
CBC--------Hct, Hb HIV test
U/A-------- UTI
Serum electrolytes---
↑Na+, ↓K+
stool exam---
parasites
chest X-ray-
Pneumonia ,TB
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