Approach to a baby who fails to thrive

Definition

• Physical growth is significantly less than that of his/her peers
• Usually refers to growth below the 3rd or 5th percentile or a change in growth that has crossed two major growth percentile(i.e., from above the 75th percentile to below the 25th )in a short time.

FTT Criteria

• Height/Weight less than 3rd to 5th percentile for age on >1 occasion
• Height or Weight falling 2 major percentiles
• < 80% of ideal body Weight for age
• Head circumference important, but not part of FTT entity

It occurs because of

• Failure of the parent to offer an adequate amount of calories
• Failure of the child to take sufficient amount of calories
• Failure of the child to retain sufficient calories

Causes

• It may be due to different organic diseases
• Or it is caused by psychosocial (nonorganic) causes

A. Inorganic causes

Prenatal factors

• Malnourished mothers
• Teenage pregnancies
• Unwanted pregnancies
• Maternal eating disorders(eg, anorexia, bulimia)
• multiple gestations

Postnatal factors

• Poor feeding or feeding-skills disorder
• Difficult parent-child interactions
• Lack of support (eg, no friends, no extended family)
• Lack of preparation for parenting
• Family dysfunction (eg, divorce, spouse abuse, chaotic family style)
• Child neglect
• Emotional deprivation syndrome
• Feeding disorders (eg, anorexia, bulimia)

B. Organic causes

Prenatal causes

• Prematurity with complications
• Toxic exposure in utero (Alcohol, smoking, medications, infections
• Chromosomal abnormalities

Postnatal causes
Inadequate intake

• Lack of appetite (eg, iron deficiency anemia, CNS pathology, chronic infection)
• Inability to suck or swallow: cleft palate, Pierre Robin Syndrome, Neuromuscular incoordination, cerebral palsy, brain stem tumor
• Vomiting (eg, CNS, metabolic, obstruction, renal)
• Dysphagia eg. gastroesophageal reflux and esophagitis

Poor absorption and/or use of nutrients

• GI disorder (eg, celiac disease, chronic diarrhea, protein-losing enteropathy, Short gut syndrome)
• Renal: renal failure, renal tubular acidosis
• Endocrine: hypothyroidism, diabetes mellitus, growth hormone deficiency
• Inborn error of metabolism
• Chronic infection (eg, HIV, tuberculosis, parasites)

Increased metabolic demand

• Hyperthyroidism
• Chronic disease (eg, heart failure, BPD)
• Chronic inflammatory conditions (eg, inflammatory bowel disease,
  lupus erythematosus)
• Renal failure
• Malignancy

History

• Age- help to determine the cause – perinatal infections, inborn errors of metabolism, cystic fibrosis
• Sex- females are more vulnerable due to social factors
• Occupation of the parents
• Presenting complaints ranges simply from not gaining weight to global developmental delay or features of some organic diseases.
• History to rule out organic causes
• 1. – unable to swallow, diarrhea, vomiting, fatty stools, food refusals ( GI problems)
  2. – urine color, frequency, output, ( urinary problem)
  3. – breathing difficulties, fever, recurrent pneumonia (respiratory/cardiac problems)
  4. -Persistent fever, weight loss ( chronic infection)

Past Medical History
Events during pregnancy

• weight gain during pregnancy
• Gravida, Parity, Abortions
• infectious diseases the mother had during pregnancy
• whether she smoked cigarettes or used drugs or alcohol.

Birth and early neonatal history

• Hospital/home delivery
• Mode of delivery and complications, if any
• APGAR scores
• Gestational age
• Small for gestational age
• Perinatal infection to mother
• Neonatal course & complications, including sepsis,jaundice, feeding intolerance, or feeding difficulties

History of breastfeeding

• infrequent or brief feedings
• nipple problems, inadequate milk secretion and poor sucking.
• maternal ingestion of a milk suppressant (e.g., alcohol)

The feeding history
-Frequency of feeding
-An error in the preparation of formula or improper feeding technique.
-Timing of weaning
-Quality and the quantity of the food
-Food refusal by the child
Immunization history 

History of developmental milestones 

Psychosocial history

• marital stress, divorce
• Unemployment and financial difficulties,
• parental absences,
• social isolation and substance abuse,
• degree of interest and concern the parents have for the child, amount of time they spend
• Whether the child was planned or “wanted”

Family history
-Similar problem in siblings
-History of consanguinity
-Weight and height of the child’s parents, grandparents – give clues about the presence of genetic, chromosomal or metabolic disorders.
-Education level of parents
-Contact history with tuberculosis
-Mental illness in the family

Physical examination

• General appearance -dull vacant stare
• poor hygiene
• passive or irritable infant
• Vital signs are important
  • Blood pressure
  • Pulse rate
  • Temperature
  • Respiration rate
  • Oxygen saturation
• Anthropometric measurements (all below 3rd percentiles or cross 2 growth percentiles)

Weight
height
head circumference

• Developmental assessments
  • Delay in the development of gross motor function as a result of neuromuscular weakness.
  • Expressive language development and social skills – may be delayed in children with nonorganic failure to thrive
• failure to thrive in infancy is associated with adverse intellectual outcomes sufficiently large to be of importance at a population level. (J Child Psychol Psychiatry. 2004 Mar;45(3):641-54)
• Undress the baby and head to toe examination

-Skin rashes and hair changes, pallor, signs of vitamin deficiencies
-Head -small and abnormal shape, dysmorphic face, cleft palate, cleft lip, low set ear, protruding tongue
-Chest-abnormal shape, abnormal Breath sounds, Cardiac examination for murmurs or cardiomegaly or arrhythmias
-Protruding abdomen, organomegaly masses
-Wasted buttocks
-Thin limbs or edematous

Laboratory work up

• complete blood count (screens for anemia or low blood counts),
• erythrocyte sedimentation rate(which can be elevated with inflammation or infections),
• urinalysis and urine culture (can show evidence of a renal tubular acidosis or chronic renal disease or infections),
• blood chemistry tests (renal function tests, liver function tests, mineral levels (calcium, magnesium, lead),
• stool tests for fat, culture, and parasites,
• sweat chloride test (for cystic fibrosis),
• HIV test,
• Mantoux test (for tuberculosis)
• serum glucose to look for diabetes,
• thyroid function tests,
• blood and urine tests to look for metabolic problems, and
• upper or lower gastrointestinal endoscopy for persistent vomiting and/or chronic diarrhea
• Radiological studies as indicated chest X-ray, other x-rays to see bone age, occult trauma due to child abuse, CT scanning head to look for micro/macrocephaly, brain atrophy, congenital malformations
• Metabolic and endocrinological screenings

Management

• Identification of the underlying cause & its correction
• Nutrition intervention or feeding behavior modification
• High-calorie diet for catch up growth
• Education to Parents or caregiver

Recommendations for Energy Intake

Adapted with permission from Hay WW.

Current pediatric diagnosis and treatment. 15th ed. Norwalk, Conn.: Appleton & Lange, 2001:250.

• Close follow up with growth monitoring
• If a cause is not apparent after a thorough history, physical examination & preliminary lab. evaluation then hospitalization may help identify inadequate calorie intake or psychosocial problems.

Indications for hospitalization

• weight below birth weight at 6 Wks
• very young infant
• failure of out-patient therapy
• work-up needed for organic causes
• unsafe home

Summary: G.R.O.W.T.H.

• Gather history and extensive physical examination
• Remember genetic contribution
• Only order basic labs in the initial evaluation
• Wonder about zebras
• Track growth trends
• Hospitalize if required