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Failure to thrive

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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]