Failure to Thrive

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Failure to Thrive

• Ken Quinto, MD, MPH

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Failure to Thrive

• Final common pathway of medical, psychosocial,
  and environmental processes that lead to poor
  growth

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Epidemiology

• Prevalence of low weight for age is 4.1 in 2 -
  6yo children
• Risk Factors
• Low socio-economic families
• Poverty
• Food insecurity
• FTT exists in all SES groups

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Epidemiology

• More than 80 of all pts with inadequate growth
  do not have any identified underlying medical
  disorder

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Definition of FTT

• Failing to grow at a rate consistent with
  expected standards for infants and toddlers
  younger than 3 yo

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Pathogenesis

• Inadequate caloric intake to meet caloric
  expenditure
• Loss of calories through malabsorption
• Increased caloric expenditure
• Inadequate intake of calories

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Types of FTT

• Organic FTT
• Pt has grown poorly and has medical disorder
  known to interfere with growth
• Multifactorial FTT
• Organic and nonorganic factors contributing to
  poor growth
• Nonorganic FTT
• Pt has grown poorly with no identified medical
  condition

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Organic FTT Causes

• Neurologic
• Cardiac
• Gastro-intestinal
• Congenital anomalies

• Cystic Fibrosis
• Respiratory
• Urinary
• Endocrine

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Non-organic FTT Causes

• Lack of education/preparation for parenting
• Lack of family resources
• Parental dysfunction
• Difficult infant
• Parent-child interaction problems
• Family system dysfunction

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Determination of FTT etiology

• abnormal losses
• vomiting
• diarrhea
• other health problems
• developmental milestones
• chronic illness
• parental attitude

• childs intake
• amount
• frequency
• diet
• feeding routine
• caretaker
• difficulties
• daily routine

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Historical Indicationsof Non-organic FTT

• history of adequate intake
• no history of abnormal losses
• lack of recognition for the problem
• pattern of neglect

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Physical Indications ofNon-organic FTT

• prominent ribs and bones
• thin limbs, wasted buttocks
• sparse, fragile hair
• protuberant belly
• decreased activity, apathy
• dull, vacant stare
• low weight (2 S.D. below mean)

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Changes in growth due to FTT

• early finding
• weight
• late findings
• length
• head circumference

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Growth charts of an 8 month old boy with
Non-organic FTT
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Work Up

• HP
• Nutritional history
• Mixing infant formula
• Feeding behavior history
• Height and weight trajectories of parents and
  siblings

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Laboratory Tests - no uniform FTT evaluation

• Review newborn screen
• urinalysis and culture
• electrolyte analysis
• daily weights with calorie count
• Screen for Fe deficiency, Pb poisoning, TB
• optional
• HIV testing
• skeletal survey
• other

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The role of hospitalization

• Frank neglect
• To show pt can gain wt when given adequate
  calories
• When feeding cant be observed as outpt
• Pts with severe eating d/o

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Prognosis

• Almost all children show adequate improvement of
  dietary intake w/o intervention as they grow older

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Calorie Counts

• Formula 20 cal/oz
• Ounce 30ml
• Example
• 7 kg hospitalized infant takes 540ml of Similac
  Advanced during 24 hours
• How many calories/kg is he taking?

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Calorie Counts

• 540ml 30ml/oz 18 ounces
• 18 ounces x 20 cal/oz 360 calories
• 360 calories 7kg 51 cal/kg
• This is not adequate for growth.
• How many ounces/day does the child need?

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Calorie Counts

• This infant needs at least 100cal/kg/day for
  growth
• 7kg x 100 cal/kg/day 700 cal/day
• 700 cal/day 20 cal/oz 35 ounces/day