Failure to thrive (FTT)

IKG Suandi Department of Pediatrics, School of Medicine Udayana University/Sanglah Hospital

Objectives
To understand the definition and criteria of patient with failure to thrive (FTT) To understand the cause or pathophysiology of patient with failure to thrive (FTT)

To understand the prevention or to refer of patient with failure to thrive (FTT)

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Definition
A term Failure to thrive: first was used to describe the malnourished1 and depressed condition of many institutionalized infants2 in the early 1900s. It remain a descriptive rather than a diagnostic label applied to children whose attained weight3 or rate of weight gain is significantly below that of other children of similar age and same sex4.
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Table 1. Definitions of Failure To Thrive (FTT)

Attained growth
Weight < 3rd percentile on NCHS growth chart Weight for height < 5th percentile on NCHS growth chart Weight 20% or more below ideal weight for height Triceps skin fold thickness < 5 mm

Rate of growth
Depressed rate of weight gain
< 20 g/d from 0-3 months of age < 15 g/d from 3-6 months of age

Fall-off from previously established growth curve

Downward crossing of > 2 major percentiles on NCHS growth chart

Documented weight loss

Figure 1. The curve of patient with FTT

Delayed 8 weeks or more

Figure 2. The curves of patient with FTT

(Weight)

(Height)

normal

(Head circumference)

Etiology(1)
Growth failure in infancy and childhood can result from a wide range of factors, including:
Serious medical disease Dysfunctional child-caregiver interactions Poverty Parental misinformation Child abuse

In majority of cases an underlying organic etiology is not found; when one is identified, it rarely presents with growth failure as its only manifestation.
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Figure 3. Nonorganic FTT

Etiology(2)
Psychosocial problems resulting in growth failure are common and should no longer be preserved as diagnoses of exclusion. Whether the condition is primary organic or psychosocial in origin, all children who are failing to thrive suffer the physical and psychological consequences of malnutrition and are at significant risk for long-term physical and psychodevelopmental squelae.

Figure 4. Organic etiology (intestinal malrotation)

Abnormal bands

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Figure 5. Pedigree patient with FTT

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Figure 6. Pedigree patient with FTT

Carrier F1 :

F2 :

Unaffected grand father

Unaffected grand mother or grand father Unaffected Mr. A Mrs. A

Carrier grand mother

F3 :

F4 :

Unaffected 8 year old unaffected 18 month old Affected

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Table 2. Causes of inadequate weight gain

1. Inadequate intake: Poverty, misperceptions about diet & feeding practices, error in formula constitution, dysfunctional parent-child interaction, mechanical problems with suck-swallow-feeding, systemic disease resulting in anorexia/food refusal. 2. Calorie wasting: Persistent vomiting, mal-absorption and/or chronic diarrhea, renal losses.

3. Increased caloric requirements: Congenital heart disease, chronic respiratory disease, neoplasm, hyperthyroidism, chronic or recurrent infection.
4. Altered growth potential/regulation: prenatal insult, chromosomal abnormality, endocrinopathies.

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Table 3. Factors influencing nutritional inadequacy in the elderly population

Physiologic
Decreased taste
Decreased smell Dysregulation of satiation Delayed gastric emptying

Pathologic
Dentition
Dysphagia, swallowing problems Diseases (cancer, CHF, COPD, diabetes, ESRD, thyroid) Medication (diuretic, antihypertensive, dopamine agonist, antidepressant, antibiotic, antihistamine) Alcoholism Dementia

Sociologic
Ability to shop for food
Ability to prepare food Financial status Low socioeconomic Impaired activities of daily living skills

Psychologic
Depression
Anxiety Loneliness

Emotionally stressful life events

Decreased gastric acid Decreased lean body mass

Lack of interactions with others at mealtime

Grief Dysphoria

CHF = congestive heart disease; COPD = chronic obstructive pulmonary disease; ESRD = end stage renal disease

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Keys of aspects of the evaluation

Keys of aspects of the evaluation include a review of past and present growth data:
a thorough history and physical examination a developmental/behavioral assessment observation of a feeding assessment of both situation-specific and global childparent interaction and selected laboratory studies based on concerns raised by the above
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Diagnosis(1)
A child who growing poorly should focused on:
Identifying signs and underlying disease. Severity of malnutrition. Important concomitant findings such as evidence of physical abuse/neglect or the presence of deprivational behaviors.

The parent-child interaction

Watching a feeding session is an excellent way to identify specific behavioral or interactional problems that occur during feeding.
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Figure 7. Enteropathology of patient with diarrhea and FTT

Abnormal villous & mucosa

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Figure 8. Organic abnormality of a patient with FTT

Abnormal brain

Distended abdomen

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(2) Diagnosis Diagnosis

Psychomotor developmental assessment

Children with severe psychosocial failure to thrive may manifest a variety of gaze disturbances ranging from hyperalert wary watchfulness to total avoidance of eye contact and apathetic withdrawal. Infants may resist cuddling and prefer interactions with inanimate objects, while toddlers may demonstrate indiscriminate affection-seeking behaviors. Many of these children also manifest developmental delay, especially in the areas of language and social adaptive behavior that are most dependent on environmental stimulation.
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Figure 9. Patients with FTT

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Diagnosis(3)
Laboratory diagnostic should be guided by:
Concern rise in the history, physical examination, and review of growth data. Organic disease presenting only with growth failure is extremely uncommon. Depending on the length and severity of growth failure, additional laboratory studies may be useful to help assess nutritional status and the presence of concomitant problems such as iron deficiency anemia Most children receive a complete blood count, serum electrolyte, serum creatinine, total protein/albumin, urinalysis, urine culture, and bone age (if height growth also poor).
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Management(1)
Most of children with growth failure can be evaluated and manage as out patients, with several important exceptions. Children with psychosocial failure to thrive should be hospitalized if they manifest evidence of, or are at high risk for, physical abuse and/or severe neglect, are severely malnourished or medically unstable, or have failed a trial of outpatient management.

The success of treatment often depend on the establishment of positive and caring longitudinal alliance with the child and caretakers.
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Management(2)
Management of psychosocial failure to thrive must be individualized to the specific needs of the child and family. Nutritional rehabilitation: efforts are focused on correcting the dysfunctional child-parent interactions by addressing areas of parental misinformation, providing and helping to implement specific feeding guidelines, and addressing the larger psychosocial needs of the family. A multidisciplinary team approach involving the primarycare provider, nutritionist, social worker, child behavior specialist, and community-based outreach services is often most beneficial.
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Summary

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