Failure to thrive refers to children whose weight or weight gain is significantly below others of the same age and sex. It can have medical causes like genetic disorders, organ defects, or infections, as well as non-medical causes like poor nutrition or emotional deprivation. Doctors evaluate growth charts, development milestones, medical history, and examine the child to look for causes and rule out normal variation. Treatment depends on the underlying cause, such as improving nutrition, treating medical conditions, or addressing psychosocial factors. Failure to thrive that continues long-term can cause permanent delays, but correcting the cause early often allows normal growth and development to resume.
Failure to thrive refers to children whose weight or weight gain is significantly below others of the same age and sex. It can have medical causes like genetic disorders, organ defects, or infections, as well as non-medical causes like poor nutrition or emotional deprivation. Doctors evaluate growth charts, development milestones, medical history, and examine the child to look for causes and rule out normal variation. Treatment depends on the underlying cause, such as improving nutrition, treating medical conditions, or addressing psychosocial factors. Failure to thrive that continues long-term can cause permanent delays, but correcting the cause early often allows normal growth and development to resume.
Failure to thrive refers to children whose weight or weight gain is significantly below others of the same age and sex. It can have medical causes like genetic disorders, organ defects, or infections, as well as non-medical causes like poor nutrition or emotional deprivation. Doctors evaluate growth charts, development milestones, medical history, and examine the child to look for causes and rule out normal variation. Treatment depends on the underlying cause, such as improving nutrition, treating medical conditions, or addressing psychosocial factors. Failure to thrive that continues long-term can cause permanent delays, but correcting the cause early often allows normal growth and development to resume.
http://www.nlm.nih.gov/medlineplus/ency/a rticle/000991.htm Failure to thrive is a description applied to children whose current weight or rate of weight gain is significantly below that of other children of similar age and sex Causes Infants or children that fail to thrive seem to be dramatically smaller or shorter than other children the same age. Teenagers may have short statureshort stature or appear to lack the usual changes that occur at puberty. However, there is a wide variation in normal growth and developmentnormal growth and development. In general, the rate of change in weight and height may be more important than the actual measurements. It is important to determine whether failure to thrive results from medical problems or factors in the environment, such as abuse or neglect. There are multiple medical causes of failure to thrive. These include: ChromosomeChromosome abnormalities such as Down syndrome and Turner syndromeTurner syndrome Defects in major organ systems Problems with the endocrine system, such as thyroid hormone deficiency, growth hormone deficiency, or other hormone deficiencies Damage to the brain or central nervous system, which may cause feeding difficulties in an infant Heart or lung problems, which can affect how oxygen and nutrients move through the body Anemia or other blood disorders Gastrointestinal problems that result in malabsorption or a lack of digestive enzymes Long-term gastroenteritis and gastroesophageal reflux (usually temporary) Cerebral palsyCerebral palsy Long-term (chronic) infections Metabolic disorders Complications of pregnancy and low birth weight Other factors that may lead to failure to thrive: Emotional deprivation as a result of parental withdrawal, rejection, or hostility Economic problems that affect nutrition, living conditions, and parental attitudes Exposure to infections, parasites, or toxins Poor eating habits, such as eating in front of the television and not having formal meal times Many times the cause cannot be determined. Symptoms Infants or children who fail to thrive have a height, weight, and head circumferencehead circumference that do not match standard growth charts. The person's weight falls lower than 3rd percentile (as outlined in standard growth charts) or 20% below the ideal weight for their height. Growing may have slowed or stopped after a previously established growth curve. The following are delayed or slow to develop: Physical skills such as rolling over, sitting, standing and walking Mental and social skills Secondary sexual characteristics (delayed in adolescents) Exams and Tests The doctor will perform a physical exam and check the child's height, weight, and body shape. A detailed history is taken, including prenatal, birth, neonatal, psychosocial, and family information. A Denver Developmental Screening Test reveals delayed development. A growth chart outlining all types of growth since birth is created. The following laboratory tests may be done: Complete blood count (CBC) Electrolyte balance Hemoglobin electrophoresis to determine the presence of conditions such as sickle cell disease Hormone studies, including thyroid function tests X-rays to determine bone age Urinalysis Treatment Treatment The treatment depends on the cause of the delayed growth and development. Delayed growth due to nutritional factors can be resolved by educating the parents to provide a well-balanced diet. If psychosocial factors are involved, treatment should include improving the family dynamics and living conditions. Parental attitudes and behavior may contribute to a child's problems and need to be examined. In many cases, a child may need to be hospitalized initially to focus on implementation of a comprehensive medical, behavioral, and psychosocial treatment plan. Do not give your child dietary supplements like Boost or Ensure without consulting your physician first. Outlook (Prognosis) If the period of failure to thrive has been short, and the cause is determined and can be corrected, normal growth and development will resume. If failure to thrive is prolonged, the effects may be long lasting, and normal growth and development may not be achieved. Possible Complications Permanent mental, emotional, or physical delays can occur. When to Contact a Medical Professional Call for an appointment with your health care provider if your child does not seem to be developing normally. Prevention The best means of prevention is by early detection at routine well-baby examinations and periodic follow-up with school-age and adolescent children. Update Date: 8/2/2009 Updated by: Neil K. Kaneshiro, MD, MHA, Clinical Assistant Professor of Pediatrics, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Growth and Failure to Thrive "Failure to thrive is a description applied to children whose current weight or rate of weight gain are significantly below that of other children of similar age and sex." 1
It is a term that tends to be applied to young children, especially babies rather than older children or teenagers. Failure to thrive (FTT) is a descriptive term or cause for concern. It is not a disease and a cause must be sought. Epidemiology This definition is (quite appropriately) rather loose. It does not specify being below the 2nd, 5th or 10th centile, as this would, by definition, include 2, 5 or 10% of all babies, even without pathology. Hence it is impossible to give meaningful figures for incidence but it is a fairly common problem.
What is more important than a single measurement is falling through the centiles. Assessing normality When assessing growth in all children, both height and weight should be considered and in small children, head circumference too.
To diagnose failure to thrive, it is imperative to understand normal growth and variation. For example, it is normal for a baby to lose up to 10% of body weight in the first few days of life. This is rapidly regained but more slowly in breast-fed babies. In our quest to avoid FTT it is important not to encourage obesity in children instead. Premature babies For premature babies a "corrected age" should be used, based on time since birth minus degree of prematurity. Thus a baby who was born 12 weeks ago at 32 weeks' gestation is treated as a 4 weeks old baby. Growth charts based on gestational age rather than chronological age are available for infants from 26 weeks' gestational age but they are synthesised from a relatively small number of infants with variable problems and so they should be treated with caution. 2
A premature baby should have reached "normality" for head circumference at around 18 months, for weight at about 24 months and for height at above 40 months. Thereafter normal charts may be employed but some premature babies with very low birth-weight do not catch up until 5 or 6 years old.
There are also specific reference charts for Down's syndrome and Turner's syndrome. Presentation Diagnosing that abnormality exists is fundamental to this issue and it is discussed in much more detail in Centile Charts and Assessing Growth. This article will focus instead upon the many causes of failure to thrive.
There are separate centile charts for boys and girls, as the former tend to be bigger. There may well be some racial differences too. Children of Indian race are often a little smaller than those of European origin and it is inappropriate to cause undue concern over a child who is obviously happy and well. Look at the parents. Tall parents have tall children and short parents have short children. Obesity is an acquired rather than a hereditary condition, although there may be some genetic factors.
The genetic components of height and weight tend to become manifest between birth and 2 years of age. Hence children of small parents may fall through the centile charts. The height and weight should be on roughly the same centiles and look at the height of the parents. Radiological bone age is also normal. About 25% of normal children will shift to a lower centile line in the first 2 years of life. If there are small parents and a healthy, happy child, there is no cause for concern. 3
Look at the charts but do not forget to look at the child. History Start by looking at the history of the pregnancy with regard to: Smoking Alcohol consumption Use of medications Any illness during the pregnancy As a general rule, placental insufficiency will lead to a small-for-dates baby who emerges hungry and eager to feed. Examine infant feeding: o With bottle-fed babies it is easy to see exactly how much is taken at each feed. o With breast-feeding this is much harder without test feeding. o Does the child seem content with the feed, dissatisfied and craving more or disinterested? Ask about the frequency of wet nappies and dirty nappies. Ask about the nature of the stool: o Remember that it is highly variable in quality and quantity in small babies, especially if breast-fed. o Chronic diarrhoea will result in failure to gain weight. Ask about illness in the child. Meningitis, fits and cerebral palsy may all cause or indicate problems. Note how the mother interacts with the child. Is she caring and concerned or cold and distant? Examination Look at the baby: Does this look a healthy, lively and active child? Are there any features suggestive of a syndrome such as Down's syndrome or Turner's syndrome? Does the child look well-nourished or starved? Note any other obvious features such as: o Cyanosis o Tachypnoea o Jaundice When picked up, does muscular tone feel normal and does the baby respond as if used to affection? Is the child alert and responsive? Plot height, weight and head circumference on a chart. If possible, plot earlier readings too, as trends or falling through the centiles are much more important than isolated readings.
Note pulse rate and respiratory rate. Possibly blood pressure and even arterial blood gases are required. Blood gas analysis may prevent excessive diagnosis of renal tubular acidosis. 4
Other physical signs may include: Oedema Hepatomegaly Rash or skin changes Hair colour and texture abnormalities Signs of vitamin deficiency Marasmus is pure calorie malnutrition but it can mimic dehydration. Features of dehydration include: Decreased skin turgor Sunken anterior fontanelle Dry mucous membranes Absence of tears Acutely ill appearance Differential diagnosis There is a very wide range of causes of FTT and more than one may be applicable.
Pre-natal causes of FTT include: Prematurity with complications Maternal malnutrition Toxic exposure in utero, including alcohol, smoking, medications, infections Intrauterine growth retardation (IUGR) Chromosomal abnormalities IUGR often produces a small but hungry and eager baby. However, a combination of pre-term and small-for-dates is more likely to cause difficulties.
Toxins in utero may include tobacco, drugs of abuse, especially amfetamines and cocaine and alcohol. Fetal alcohol syndrome may occur or the incomplete fetal alcohol effects. Infection in utero may include rubella, toxoplasmosis and cytomegalovirus.
Postnatal causes include lack of adequate intake of nutrition: Lack of appetite may occur with iron deficiency anaemia, CNS pathology and chronic infection Inability to suck or swallow, especially with CNS or muscular disorders Vomiting due to CNS or metabolic diseases, obstruction or renal disorders Gastro-oesophageal reflux and oesophagitis Physical problems of feeding may occur with cleft palate, hypotonia, micognathia and Prader-Willi syndrome.
Poor absorption or metabolism of nutrients occurs with: Gastro-intestinal disorders including cystic fibrosis, coeliac disease and chronic diarrhoea Renal failure or renal tubular acidosis Endocrine abnormalities including hypothyroidism, diabetes mellitus, growth hormone deficiency Inborn errors of metabolism Chronic infection including congenital HIV, tuberculosis, parasites Increased metabolic demand occurs with: Hyperthyroidism Chronic disease such as heart failure and broncho-pulmonary dysplasia Renal failure Malignancy Non-organic or "functional" causes of FTT may include: Poor feeding, possibly caused by ignorance and lack of supervision and help (no friends, no extended family). Are feeds made up properly? Lack of preparation for parenting Family dysfunction (e.g. divorce, spouse abuse, chaotic family style) Difficult child Child neglect (there may be puerperal depression) Emotional deprivation syndrome The mother may have an eating disorder but more often they tend to over-feed the rest of the family Mnchhausen's syndrome by proxy Investigations Investigations are usually guided by history and examination. Routine tests may include: FBC Urinalysis Urine culture U&E and creatinine LFTs, including total protein and albumin Prealbumin may be used as a nutritional marker The following tests are not usually routine but may be indicated by history and examination: Testing for HIV infection Sweat chloride test Thyroid function tests Stool studies for parasites or malabsorption Immunoglobulins Purified protein derivative (PPD) skin test (for tuberculosis) Radiological studies (bone age may be helpful to distinguish genetic short stature from constitutional delay of growth) Special tests may be used for coeliac disease or to detect growth hormone deficiency. Associated diseases Look for problems in the mother as well as problems in the child. Puerperal depression may present with the child failing to thrive. Management Management will depend upon the underlying cause. With syndromes such as Turner's or Down's, it may be that use of the correct charts shows that growth is as expected. Physical illness such as cyanotic congenital heart disease, cystic fibrosis or coeliac disease needs treating accordingly. High calorie feeding may be required but this needs specialist help or overloading the gut causes diarrhoea and is counterproductive. If the mother is not coping, she needs help and advice with plenty of input from the health visitor. 5 It may be necessary to remove the baby, especially in Mnchhausen's syndrome by proxy, but this should not be done without considerable thought and attempts to rectify the situation. The potential value of a specialist health visitor is uncertain. 6
If improvement in the community is inadequate, admission to hospital may permit more intense observation and support. If the child thrives under these conditions, it is highly suggestive of poor parenting skills. Puerperal depression may need to be treated. Support and supervision is needed in the meantime. The baby may need to be put on the at risk register with multidisciplinary input until such time as it is deemed safe to remove the name. Complications There is a fear that failure to thrive may result in long-term stunting of growth and cognitive developmental delay. This may be compounded if there is emotional neglect too. 7 However, when corrections are made for maternal IQ, cognitive impairment does not appear to be so much of a problem as was thought. 8 Long term effects on height and weight appear to be more marked than on IQ. 9
Prognosis As a general rule, if small babies double their birth weight in 4 months and triple in a year, they will catch up.
A systematic review concluded that the long-term outcome of FTT is a reduction in IQ of about 3 points, which is not of clinical significance. 10
Prevention Good antenatal care and avoidance of toxins such as illicit drugs, tobacco and alcohol in pregnancy will reduce the risk. Parenting classes should lead to a better understanding of the needs of the baby. Nowadays fathers are often involved too and this is to be welcomed. An astute midwife or health visitor should detect problems before they become serious. The general practitioner and primary healthcare team are in a difficult position and have to strike a balance between being accused of failure to recognise FTT and causing excessive and unnecessary alarm over healthy babies. 11
Document references 1. MedlinePlus; Failure to thrive (FTT) 2. Sherry B, Mei Z, Grummer-Strawn L, et al; Evaluation of and recommendations for growth references for very low birth weight (< or =1500 grams) infants in the United States. Pediatrics. 2003 Apr;111(4 Pt 1):750-8. [abstract] 3. Krugman SD, Dubowitz H; Failure to thrive; American Family Physician Vol. 68/No. 5 (September 1, 2003) [full text] 4. Adedoyin O, Gottlieb B, Frank R, et al; Evaluation of failure to thrive: diagnostic yield of testing for renal tubular acidosis. Pediatrics. 2003 Dec;112(6 Pt 1):e463. [abstract] 5. Wright CM, Callum J, Birks E, et al; Effect of community based management in failure to thrive: randomised controlled trial. BMJ. 1998 Aug 29;317(7158):571-4. [abstract] 6. Raynor P, Rudolf MC, Cooper K, et al; A randomised controlled trial of specialist health visitor intervention for failure to thrive. Arch Dis Child. 1999 Jun;80(6):500-6. [abstract] 7. Mackner LM, Starr RH Jr, Black MM; The cumulative effect of neglect and failure to thrive on cognitive functioning. Child Abuse Negl. 1997 Jul;21(7):691-700. [abstract] 8. Drewett RF, Corbett SS, Wright CM; Cognitive and educational attainments at school age of children who failed to thrive in infancy: a population-based study. J Child Psychol Psychiatry. 1999 May;40(4):551-61. [abstract] 9. Boddy J, Skuse D, Andrews B; The developmental sequelae of nonorganic failure to thrive. J Child Psychol Psychiatry. 2000 Nov;41(8):1003-14. [abstract] 10. Rudolf MC, Logan S; What is the long term outcome for children who fail to thrive? A systematic review. Arch Dis Child. 2005 Sep;90(9):925- 31. Epub 2005 May 12. [abstract] 11. Batchelor JA; Has recognition of failure to thrive changed? Child Care Health Dev. 1996 Jul;22(4):235-40. [abstract]