Failure to Thrive in Children: Recognizing and Managing this Concerning Condition

As a pediatrician who has treated infants and children with failure to thrive for over 20 years, I have gained valuable clinical experience in both developing and developed countries. Failure to thrive, characterized by insufficient weight gain and growth, can have serious impacts if not managed promptly. In this post, I will share key insights on recognizing, evaluating, and treating failure to thrive based on my practice in diverse global settings.

Recognizing the Red Flags of Failure To Thrive Early

Growth trends are a key indicator, and certain patterns should raise concern for failure to thrive:

– Failure to double birth weight by 4 months of age
– Failure to triple birth weight by 12 months of age
– Weight consistently below the 5th percentile for age after ruling out constitutional small stature
– Length consistently below the 5th percentile for age
– Crossing two or more major weight percentile lines in either direction
– Weight less than 75% of the median weight for age (Cole & Lanham, 2011)

For example, I cared for a 9-month-old infant many years ago who presented with a weight in the 3rd percentile. She had been born full term at 50th percentile but fell off her growth curve over several months. Her length was at the 10th percentile, indicating disproportionate growth. This trend warranted a full failure to thrive evaluation.

Sometimes failure to thrive develops gradually, so tracking growth data over time is key. That is why we are always insisting on it at Omega Pediatrics. At routine wellness checks we always plot weight, length, and head circumference to catch any faltering growth early on. We  also calculate the weight-for-length ratio to account for constitutional variations which may be seen due to racial differences or family genetics.

Diagnostic Evaluation of Children for Failure To Thrive (FTT)

When failure to thrive is suspected, we generally perform a thorough history and physical exam searching for potential causes – a given in any serious illness anyway. Asking about the child’s diet history, feeding behaviors, medications, and family circumstances may give us a clue as to the source and cause.

The physical exam includes a dental evaluation (not comprehensive but at least we try to look) to identify problems that could impair adequate eating such as sores in the mouth or severely damaged teeth.

The  laboratory tests are ordered based on findings from the history and exam. Common tests include:

– Complete blood count (CBC)
– Comprehensive metabolic panel
– Thyroid function
– Celiac screening
– Inflammatory markers

I also consider testing for urinary tract infections, stool pathogens, HIV, and tuberculosis depending on the clinical picture. Radiographic studies like GI imaging may be warranted if malabsorption is suspected.

I recall ordering celiac blood tests for a 22-month-old girl with failure to thrive whose parents reported chronic diarrhea and a distended belly with eating. The positive celiac panel supported our diagnosis, and a gluten-free diet led to improved growth. Normally we defer to the Pediatric GI specialists for testing and we strongly encourage that mode of practice.

Key Aspects of Management of FTT

Two core strategies are essential when creating a management plan: providing adequate calories to promote catch-up growth, and consistent follow-up to monitor progress.

In calorie-deficient failure to thrive, that is when the cause is because of poor caloric intake, I recommend 150% of the child’s recommended daily caloric intake based on age and expected weight. A 3-day food diary helps guide specific diet recommendations for increased caloric density. I provide hands-on feeding advice and education on introducing nutrient-rich solid foods. These families usually benefit from a dietician meeting where available. BUt in the clinic setting I would do it myself. Initial weekly then later monthly weight checks ensure growth improvement.

For toddlers whose failure to thrive have stemmed from difficulty transitioning to solid foods, I work closely with the parents on strategies like adding cereal to increase calorie intake. I would see such children weekly for weight checks and within 2-3 months the weight climb  to the 40th percentile and beyond is impressive.

If failure to thrive is severe or the child continues to lose weight despite interventions, hospitalization for nutritional rehabilitation may be necessary to stabilize the situation. I once admitted a severely malnourished infant to initiate refeeding with total parenteral nutrition due to oral aversion. His intensive inpatient nutritional support facilitated recovery from failure to thrive within weeks. The child also needed some occupational therapy as well as speech therapy – they often know how to handle these problems with the mouth!

 Cultural Considerations Should not be overlooked in FTT

When developing a care plan for failure to thrive, it is essential to consider the family’s cultural background and values. Insight into their perspective, traditions, and beliefs can improve adherence. I always take time to establish trust and understanding, which leads to better outcomes. Those who have been here know that your visits are like visiting an Uncle or an old friend. This helps me align culturally with the family and understand their background a bit.

For instance, when I practiced in Nigeria, some families relied on herbal remedies before seeking modern medical care. Gaining their trust as a pediatrician in a big hospital enabled me to integrate their traditional practices into nutrition and feeding plans, negating the harmful practices and encouraging the ones that our medical community felt were not harmful or that were actually helpful. This improved buy-in and partnership in addressing failure to thrive.

Failure to Thrive

What is Failure to Thrive- FTT?

I will go academic a bit here especially for the students reading this.

Failure to thrive involves inadequate physical growth and weight gain in children, leading to measurements below normal growth curve standards (Homan, 2016). While causes are often complex, it generally stems from insufficient calorie intake and/or poor nutrition.

During my practice in sub-Saharan Africa, poverty, food insecurity and limited nutritional knowledge were major causes. Many families struggled to provide adequate nutrition given extremely scarce resources. Nutrition education and calorie-dense foods improved most cases.

In developed nations, medical conditions like chronic diseases and genetic disorders more commonly contribute, though social and environmental factors still play a role. I’ve diagnosed failure to thrive related to heart defects, cystic fibrosis and celiac among others. Thorough evaluation helps identify medical causes requiring treatment.

Failure to Thrive

Before We Leave

In summary, promptly recognizing failure to thrive enables timely evaluation and management to get children back on track developmentally. While causes vary, optimized nutrition and monitoring are critical for treatment. A thoughtful approach accounting for cultural factors leads to the best outcomes for this concerning childhood condition. My global clinical experiences have shown early intervention helps infants and toddlers with growth issues thrive.

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