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Basics
DESCRIPTION
A descriptive term for poor growth as a result of inadequate nutrition from a variety of possible causes.
Definition:
1. Weight for age <5th or 3rd percentile, or weight velocity depression crossing 2 percentile lines are most
frequently used.
2. Often linear growth and head circumference are less affected than weight, if at all.
3. Growth charts which correct for regression to the mean can be used.
EPIDEMIOLOGY
BASICS-EPIDEMIOLOGY-Prevalence
Prevalence of FTT ranges from 1.321%, depending on definitions used and populations studied.
In the 1980s, FTT accounted for 15% of tertiary hospital admissions for young infants. Up to 10% of infants in
some primary care settings show signs of FTT.
Diagnosis
Goal: When diagnosis of FTT has been established, the first goal is to identify possible organic causes, nonorganic causes,
and normal variants of growth. There may be more than one contributing factor.
Use standard growth charts. Trends of growth parameters over time are most useful, and can point to underlying
causes or normal variants.
Modified growth charts for specific populations or specific ethnicities can be helpful.
FTT often has negative connotations that can introduce feelings of incompetence or be associated with judgments.
Review of systems:
1. Developmental history with focus on any developmental problems
2. History of recurrent infections
3. Vomiting
4. Reflux
5. Stool: Diarrhea, pattern, frequency, consistency, presence of blood or mucus
Respiratory symptoms:
1. Chronic cough
2. Shortness of breath
3. Snoring
Physical Exam
Clefts
Dental carries
In general, after a proper history and physical exam, few tests are of diagnostic assistance.
3. Comprehensive metabolic panel including electrolytes, BUN, creatinine, liver function tests, calcium,
magnesium, and phosphorus(to evaluate for metabolic or renal disorders, liver disease, and [in severe
malnutrition] as a baseline to prevent electrolyte abnormalities associated with refeeding)
4. Urine for culture and urinalysis (for UTI and renal tubular acidosis)
Other possible tests based on history and physical (not an exhaustive list):
1. Immunoglobulins
2. Celiac screen (and total IgA)
3. Thyroid function tests
4. Blood glucose
5. Iron studies
6. Lead level
7. Stool sample
8. Stool microscopy and culture
9. Stool fat
10. PPD
11. HIV screening
12. Urine organic and serum amino acids(metabolic screen)
13. Karyotype
14. Allergy investigations: RAST, skin prick test
15. Sweat test
16. Endoscopy
17. Bone age x-rays
18. EKG
DIFFERENTIAL DIAGNOSIS
Corrections for gestational age are necessary until at least 2 years of age.
As long as growth continues along one percentile line, even if below the 5th percentile, FTT
should not be diagnosed.
Decreased appetite
Maternal depression
Central nervous system insults, including cerebral palsy and degenerative diseases
Malabsorption
Maldigestion
Celiac disease
Allergic colitis
Cystic fibrosis
Lactose intolerance
Biliary atresia
Liver disease
Hirschsprung disease
Malrotation
Chronic constipation
Short-gut syndrome
Cardiac disease
Treatment
INITIAL STABILIZATION
Avoid the refeeding syndrome, which may result in electrolyte disturbance and circulatory collapse.
GENERAL MEASURES
Treatment or management of any identified organic contributors is necessary, such as using an elemental formula in
the case of milk protein allergy.
Children with FTT need a high-calorie diet for catch-up growth, and all children with FTT need close follow-up.
Additional calories for catch-up growth are typically 150% of the caloric requirement for the expected, not actual,
weight.
A dietician/nutritionist can be helpful in setting goals and diet recommendations, which may include increased
protein with increased calories.
Catch-up growth (kcal/kg/d) guidelines for average replacement according to the patients age:
1. 10 days to 1 month, 120 kcal/kg/d
2. 12 months, 115 kcal/kg/d
3. 23 months,105 kcal/kg/d
4. 36 months, 95 kcal/kg/d
5. 6 months to 5 years, 90 kcal/kg/d
High-calorie concentrated supplementation may be needed if volume necessary for catch-up growth is not
tolerated.
If there is no improvement despite increase in calories, a multidisciplinary approach is recommended, even for mild
or moderate FTT.
Multidisciplinary approach includes doctors, nurses, dietitians, social workers, and psychologists.
Follow-up Recommendations
The FTT child should remain under long term surveillance for growth and cognitive development.
If the child is judged to be at risk, mandatory reporting to Child Protective Services, based on local guidelines,
must be followed.
Very young children should be followed every 1 or 2 weeks, and older children at least monthly until catch-up
growth is demonstrated and a positive trend is maintained.
DISPOSITION
Admission Criteria
Most cases of FTT can be managed as outpatients by the primary care practitioner. Admit all severe FTT patients
and patients with moderate dehydration or infection. Consider social factors in admission.
Consider admission for observation of feeding, parentchild interaction, and dietary habits, as well as the ability to
perform specific tests; consult subspecialists.
Discharge Criteria
Diagnostic tests and consultations requiring hospitalization have been performed (i.e., pH probe, sweat test,
occupational therapy evaluation of swallowing).
The caretaker has demonstrated an understanding of nutrition recommendations and growth expectations.
FOLLOWUP-DISPOSITION-Issues-for-Referral
In cases of continued poor growth, addressing psychosocial issues within the family is crucial and usually requires
involvement of a multidisciplinary team.
Q: If a child gains weight in the hospital, does that prove that the FTT is from a nonorganic cause?
A: There is a misconception that weight gain in a hospital or strictly supervised environment rules out organic
causes. This is not the case; weight gain can be achieved in children with organic or nonorganic causes of FTT.
A: The primary physician must consider the childs overall well-being and possible effects on long-term
neurobehavioral development. Noncompliance with nutrition recommendations, failure to appear at follow-up or
other appointments, and other signs or symptoms of neglect are all reasons that would justify referral.