Failure to thrive overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]
Overview
Various definition such as weight for age less than the 5th percentile for age, weight for height less than the 5th percentile for age or a drop in more than two percentiles on the growth chart may be used. The initial approach involves a thorough history and physical examination. The most common presenting complaint is poor growth and failure to gain weight. Nutritional interventions such as regular breastfeeding, eating with the child, measuring the caloric requirement of the child or ensuring the child eats with an upright posture should be added to psychological interventions like parent education and maintaining a discord free family environment.
Historical Perspective
Amidst rapidly rising infant and child death rates, Dr. Henry Dwight was the first to add a clean environment and constant supervision to the management strategy of failure to thrive patients. As time has progressed, red flags and the present strategy of nutritional rehabilitation followed by a vigilant and prolonged follow up period has been developed.
Classification
There is no established classification system for failure to thrive. Based on cause, it may be divided into organic and non-organic failure to thrive.
Pathophysiology
The most common cause of failure to thrive is inadequate calorie intake. This may be secondary to psychological causes, poor environmental status, poor calorie absorption and underlying medical conditions that cause excessive energy expenditure.
Causes
Causes of failure to thrive are mainly organic and non-organic. Organic causes are further divided into inadequate calorie intake, inadequate calories absorption and increased calorie expenditure.
Differentiating Failure to thrive from Other Diseases
It is important to differentiate failure to thrive into organic and non-organic causes. Furthermore, using the concepts of bone age, chronological age, catch up growth and catch down growth, conditions such as constitutional growth delay and familial short stature should also be considered.
Epidemiology and Demographics
The prevalence of failure to thrive depends on the development status of the country. Studies have suggested a prevalence rate of approximately 5% in the United States of America.
Risk Factors
It is important to differentiate risk factors from causes. Major risk factors to be considered include an unsafe, dirty environment, history of parental psychiatric illness, substance abuse, marital conflict, low birth weight, chromosomal disorders and dental caries.
Screening
There are no established screening protocols established for failure to thrive.
Natural History, Complications, and Prognosis
The most common presenting complaint is poor growth and failure to gain weight. The patient may have more specific complaints depending on the underlying cause. A few important complications include a diminished final weight and height, vitamin deficiencies and an increase risk of recurrence of failure to thrive. Not much data is available on the prognosis of failure to thrive as it is a multifactorial process. However, the duration of malnutrition is directly proportional to the cognitive and physical decline of the patient.
Diagnosis
Diagnostic Study of Choice
There is no diagnostic study of choice for failure to thrive. Various definition such as weight for age less than the 5th percentile for age, weight for height less than the 5th percentile for age or a drop in more than two percentiles on the growth chart may be used. The initial approach involves a thorough history and physical examination. This will help narrow the diagnosis, identify red flags and then determine the need for hospitalization.
History and Symptoms
The most common presenting complaint is poor growth and failure to gain weight. The patient may have more specific complaints depending on the underlying cause. A few important complications include a diminished final weight and height, vitamin deficiencies and an increase risk of recurrence of failure to thrive. Not much data is available on the prognosis of failure to thrive as it is a multifactorial process. However, the duration of malnutrition is directly proportional to the cognitive and physical decline of the patient.
Physical Examination
The patient encounter provides a good opportunity to not only physically examine the patient, but to also notice the interaction between the parents and the child. Murmurs, structural deformities such as cleft lip or palate, crackles secondary to a cystic fibrosis related pneumonia or rashes secondary to physical abuse are some important positive findings. With proper technique, anthropometric measurements should be plotted and compared with previous measurements.
Laboratory Findings
Lab investigations are ordered based on the initial history and physical examination findings.it may be ordered to uncover conditions such as iron deficiency anemia secondary to malabsorption, hyperthyroidism, renal failure or an underlying malignancy.
Electrocardiogram
There are no specific ECG findings associated with failure to thrive.
X-ray
X-rays are useful in diagnosing organic causes of failure to thrive. Listing down each organic cause is beyond the scope of this microchapter.
Echocardiography and Ultrasound
Echocardiography and ultrasounds are useful in diagnosing organic causes of failure to thrive.
CT scan
CTs are useful in diagnosing organic causes of failure to thrive.
MRI
MRIs are useful in diagnosing organic causes of failure to thrive. Listing down each organic cause is beyond the scope of this microchapter.
Other Imaging Findings
Barium swallow may be helpful in the diagnosis of failure to thrive.
Other Diagnostic Studies
There are no other diagnostic studies associated with failure to thrive.
Treatment
Medical Therapy
Appetite stimulants such as cryptoheptadine and progesterones may be employed in patients with failure to thrive. However, these are not recommended. Medical therapy employed also depends on the underlying organic cause.
Interventions
Nutritional interventions such as regular breastfeeding, eating with the child, measuring the caloric requirement of the child or ensuring the child eats with an upright posture should be added to psychological interventions like parent education and maintaining a discord free family environment.
Surgery
Surgery may be employed for certain organic causes of failure to thrive such as a renal transplant, small intestinal bowel obstruction, thyroidectomy or closure devices placed for congenital heart diseases.
Primary Prevention
Regular anthropometric measurements added to an adequate, balanced diet and a healthy environment are some important primary preventive strategies.
Secondary Prevention
There are no established measures for the secondary prevention of failure to thrive.