Failure To Thrive (FTT)Zach JarouMichigan State University College of Human MedicineJanuary 23, 2013

Evolving Definitions of FTT•FTT is not a syndrome, rather it is a

physical sign that a child is receiving inadequate nutrition for optimal growth and development

•Older dichotomous view emphasized organic (underlying medical condition, rare) vs. non-organic causes (environmental, more common)

•Now appreciated to be most commonly mixed/multi-factorial in cause

Chart-Based Definitions of FTT

Chart-Based Definitions of FTT•Children younger than 3 years of age,•Below 3rd or 5th percentile for age on more

than one consecutive occasion•Weight drops down two major percentile

lines•Whose weight is less than 80% of the

ideal weight for age•Below the 3rd or 5th percentile on the

weight-for-length curve

Pathogenesis•Loss of calories through malabsorption•Increased caloric expenditure

(hyperthyroidism, congenital heart disease, chronic pulmonary disease)

•Inadequate intake of calories (most frequent)

•Poor strength or neurologic ability to suck, chew, or swallow adequate amounts of food

Pathogenesis (cont.)•Dietary factors

▫Breastfeeding difficulties▫Improper formula mixing▫Poor transition to food (6 to 12 months of age)▫Excessive juice consumptions▫Avoidance of high-calorie foods

•Family conditions▫Inadequate knowledge of infant nutrition needs▫Mental health (depression, anxiety, substance

use)▫Family chaos, child neglect, financial hardship

Physical Exam•Neurodevelopmental status•Neurocutaneous markings•Dysmorphic features•Nutritional status•Dehyrdration•Feeding observation

▫Bottle feeding▫Spoon/self-feeding▫Creating proper social environment

Laboratory Tests• A shotgun approach is not cost-effective• Tests must be performed based on positive

findings from history and physical• Additional lab and imaging tests are completed

for children who do not respond to dietary intervnetion

• Important to review newborn metabolic screening tests for inborn errors of metabolism and hypothyroidism

• Routine tests in children 6-18 months are for iron deficiency, lead poisoning, TB, chronic UTI

Differential Diagnosis•1) FTT with microcephaly

▫TORCH infections▫Teratologic & genetic conditions▫Brain injury

•2) FTT with short stature▫Genetic syndromes (Russell-Silver, Turner,

Down)▫Endocrine (hypothyroid, hypophosphatemic

rickets, growth hormone deficiency)▫Teratologic conditions (fetal alcohol syndrome)

Differential Diagnosis•3) FTT characterized by adequate height

for age and normal head circumference▫Inadequate calories offered

(inadvertent/intentional)▫Child unwilling to accept food that is

offered (poor apetite, oral aversion, food aversion, oromotor dysfunction)

▫Caloric loss through vomiting or malabsorption or hypermetabolic state

Management•Nutritional education•Feeding intervention•Continue to monitor growth response•Treat underlying medical conditions•More serious problems such as electrolyte

disturbances and dehydration often require hospitalization

Prognosis• Almost all children show adequate improvement

with intervention• Many improve even without intervention as they

become more independent in feeding themselves when hungry

• A small percent of “picky eaters” have anxiety disorders and a few have autism spectrum disorders

• Children who require gastrostomy feeding tubes and who have neurologic dysfunction interfering with swallowing usually require enteral feeding for life

Prognosis (cont.)•Some evidence of poorer cognitive and

school outcomes of FTT children•Early iron deficiency anemia leads may lead

to irreversible developmental deficits•Children experiencing calorie malnutrition

may have also experienced environmental deficits (parental attention, emotionally/cognitively stimulating home)

•Should be monitored for developmental and behavioral problems

Pearls• FTT due to poor food intake = weight falls first, sparing length and

head circumference• Symmetric fall in weight and height suggests a chronic medical

condition• Short stature below 50th percentile with relative sparing of weight

suggests an endocrine disorder• early drop-off in head circumference suggests a lack of brain

growth• Children born with genetic conditions must have their growth

plotted on adjusted curves• Wasting = decreased weight for height, acute malnutirion,

decreased subQ fat, measured by triceps skinfold thickness• Stunting = decreased height for age, can be sign of chronic

undernutrition• Important to take into account family stature (genetic potential)

References•Gahagan S (2006). Failure To Thrive: A

Consequence of Undernutrition. Pediatrics in Review; 27 (1): e1-e11. (link)

•Jaffe AC (2011). Failure To Thrive: Current Clinical Concepts. Pediatrics in Review; 32 (3): 100-108. (link)